[exam finding]
[MedRec]
[immunochemotherapy]
This is a 50-year-old woman with newly diagnosed high-grade serous carcinoma of the ovary, FIGO stage IIIC (pT3c), status post optimal debulking surgery on 2025-05-19, and currently receiving combination chemotherapy with paclitaxel, carboplatin, and Avastin (bevacizumab), with cycles administered on 2025-06-13 and 2025-07-04. Her disease is complicated by peritoneal carcinomatosis and grade 4 fatty liver. Comorbidities include chronic hepatitis B (Anti-HBc reactive, non-viremic), hypertension, and allergic rhinitis. She is currently clinically stable with good ECOG performance (PS 1), controlled blood pressure, acceptable glycemic control (HbA1c 6.1% on 2025-06-27), and no significant cytopenias or organ dysfunction. CA125 has decreased (224.6 on 2025-04-29 → 38.31 on 2025-06-16), suggesting treatment response.
Problem 1. High-grade serous ovarian carcinoma, FIGO stage IIIC
Problem 2. Liver function and hepatic risk (grade 4 fatty liver, HBV carrier)
Problem 3. Hematologic profile and chemotherapy tolerance
Problem 4. Glycemic control and hypertension
[exam finding]
[MedRec]
[chemotherapy]
The patient is a 70-year-old female with a history of myelodysplastic syndrome (MDS) with increased blasts and fibrosis, classified as very high risk (IPSS-R: 8.5, WPSS: 5). She is currently undergoing Cycle 2 of azacitidine (Vidaza) therapy (2025-03-04 to 2025-03-10). Persistent pancytopenia (severe anemia, leukopenia, thrombocytopenia) is noted, necessitating red blood cell transfusion (2025-03-04, 2 units LPRBC planned).
Other significant findings include:
The patient’s overall condition is stable (ECOG PS 1 on 2025-03-04), with good intake, absence of fever, and mild postural dizziness.
Problem 1. Myelodysplastic Syndrome (MDS) with Increased Blasts
Problem 2. Thrombocytopenia
Problem 3. Severe Anemia (Hgb 5.5 g/dL)
Problem 4. Polyneuropathy
Final Recommendations
[Jadenu (deferasirox) is recommended]
Based on the patient’s body weight of 55 kg and a calculated deferasirox dose of 14 mg/kg (770 mg total daily dose), treatment with Jadenu (deferasirox 360 mg/tab) 2 tablets QD is recommended.
Given the ferritin level of 1136.2 ng/mL (2024-12-13), which exceeds the 1000 ng/mL threshold for iron overload, iron chelation therapy should be initiated to prevent end-organ damage associated with chronic transfusions. Regular ferritin monitoring every 4-8 weeks is advised to assess treatment response and adjust the chelation regimen as needed.
[Is Azacitidine the Cause of Thrombocytopenia?]
Vidaza (azacitidine) can cause thrombocytopenia as a known adverse effect. However, in this patient’s case, the thrombocytopenia is likely multifactorial rather than solely drug-induced.
Conclusion:
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
This is a 60-year-old woman with primary central nervous system diffuse large B-cell lymphoma (PCNS-DLBCL), stage IE, confirmed by brain biopsy on 2025-04-29. She is currently undergoing MTR chemotherapy regimen (Methotrexate, Temozolomide, Rituximab). The patient was readmitted on 2025-07-03 for Cycle 2, Day 1 high-dose methotrexate (HD-MTX) therapy. Laboratory monitoring and medication charts confirm the use of leucovorin (Covorin) as rescue therapy, consistent with high-dose MTX protocol. Renal function is stable (eGFR 54.42 on 2025-07-03), and vital signs are within acceptable ranges post-chemotherapy. No acute complications such as MTX-induced renal or hepatic toxicity are observed.
Problem 1. High-dose methotrexate-related toxicity prevention
Problem 2. Renal function under chemotherapy
Problem 3. Hematologic monitoring during MTR (not posted)
This is a 60-year-old woman with primary CNS diffuse large B-cell lymphoma (DLBCL, non-GCB, stage IE) confirmed by brain biopsy on 2025-04-29, currently undergoing induction chemotherapy with the MTR regimen (Methotrexate, Temozolomide, Rituximab). Her treatment has been complicated by prior acute kidney injury (AKI) after high-dose methotrexate on 2025-05-14, prompting a dose reduction in subsequent cycles. She was readmitted on 2025-06-12 for Cycle 1 Day 15 methotrexate infusion. As of 2025-06-13, she remains hemodynamically stable (BP range 141–170 mmHg), afebrile, fully conscious (E4V5M6), and tolerating the chemotherapy. Renal function has improved (eGFR 47.79 mL/min/1.73m²), urine output remains adequate, and methotrexate rescue (Covorin and hydration) is ongoing. No signs of sepsis, tumor lysis, or active infection are currently present.
Problem 1. Primary CNS DLBCL (Stage IE), s/p biopsy, on MTR regimen
Objective
Assessment
Recommendation
Problem 2. Renal function impairment (post-MTX AKI, now recovering)
Problem 3. Normocytic anemia (not posted)
Problem 4. Hypertension (essential, uncontrolled in past) (not posted)
[PCNS-DLBCL] (not posted)
There are clear diagnostic criteria met in the provided data to support the diagnosis of primary central nervous system diffuse large B-cell lymphoma (PCNS-DLBCL) :
Supporting Evidence:
Diagnostic Definition (per WHO 5th ed. and NCCN 2025)
A diagnosis of Primary CNS Lymphoma (PCNSL) requires:
→ The patient meets all of the above criteria, so the diagnosis of Primary CNS DLBCL, stage IE is fully supported.
[leucovorin (folinic acid) is being used to mitigate methotrexate (MTX) toxicity] (not posted)
Leucovorin (folinic acid) is clearly being used to mitigate methotrexate (MTX) toxicity in this patient, and this is fully aligned with standard oncologic protocols.
Evidence from the simulated case:
Conclusion:
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
Summary
Problem 1. Metastatic vaginal adenocarcinoma (pT2bN1M1, stage IV)
Problem 2. Chronic bilateral ureteral obstruction with recurrent right and left PCN dysfunction
Problem 3. Normocytic anemia (HGB 9.1 g/dL) (not posted)
Problem 4. Viral hepatitis B carrier (anti-HBc positive, HBsAg negative) (not posted)
Problem 5. Right lower extremity lymphedema and pain
This is a 58-year-old woman with recurrent, metastatic vaginal adenocarcinoma (pT2bN1M1, FIGO stage IV) with bilateral inguinal lymph node and right thigh involvement. After progressing through multiple chemotherapy regimens including taxanes, cisplatin, carboplatin/irinotecan, GFL, and pembrolizumab, she was recently initiated on sacituzumab govitecan (Trodelvy) with the most recent dose given on 2025-05-19. She has chronic bilateral hydronephrosis secondary to malignant ureteral obstruction, status post multiple bilateral PCN revisions (latest on 2025-05-20). Current condition is stable under immunotherapy, with preserved renal function, mild anemia, and controlled pain.
Problem 1. Refractory metastatic vaginal adenocarcinoma (stage IV, pT2bN1M1)
Problem 2. Bilateral malignant ureteral obstruction with CKD, status post PCN revision
Problem 3. Anemia of chronic disease and chemotherapy (not posted)
Problem 4. Bilateral lower limb lymphedema
Problem 5. Pain control and symptom monitoring during chemotherapy (not posted)
This is a 58-year-old woman with a history of moderately differentiated adenocarcinoma of the vagina, initially diagnosed as pT2bN1, FIGO stage III in 2022, now with progression to stage IV due to bilateral inguinal lymph node metastases and right thigh metastasis (Pathology 2024-06-06). She underwent staging surgery, CCRT, and multiple systemic regimens including cisplatin-paclitaxel-bevacizumab, carboplatin-irinotecan, GFL, and currently receiving pembrolizumab Q3W (most recent on 2025-03-31). Renal function has been chronically compromised, now requiring bilateral percutaneous nephrostomy (2024-11-18, 2024-11-19), and she has atrial flutter (ECG 2025-02-10), severe hydronephrosis (multiple imaging), and signs of progressive soft tissue metastatic disease.
Problem 1. Progressive Vaginal Adenocarcinoma (Stage IV)
Problem 2. Bilateral Hydronephrosis with Chronic Kidney Disease (not posted)
Problem 3. Atrial Flutter with AV Block
Problem 4. History of Venous Thromboembolism (VTE)
Problem 5. Skin and Soft Tissue Lesions (R’t Thigh/Pubic Region)
[Patient Review and Assessment]
The patient is a 58-year-old female with a history of vaginal adenocarcinoma (pT2bN1, FIGO Stage III), which has progressed to bilateral inguinal lymph node metastasis (current stage IV), confirmed by imaging and biopsy. She has undergone multiple rounds of chemotherapy (e.g., carboplatin, paclitaxel), radiation, and surgical interventions, including bilateral ureteral stent placements to manage hydronephrosis due to tumor compression. Recent findings also suggest right femoral vein thrombosis and recurrent complications related to tumor burden and treatment toxicity.
Current Symptoms and Complications
Treatment Remmendations and Rationale
Balancing Efficacy and Toxicity in Vaginal Cancer Therapy
[nab-paclitaxel and renal function]
Post-administration of nab-paclitaxel, serum creatinine levels have consistently remained above 1.5 mg/dL. Although there hasn’t been a rapid increase, continuous monitoring is still advised.
Nab-Paclitaxel for patients with altered kidney function, there are no dosage adjustment recommendations for those with a Creatinine Clearance (CrCl) ≥30 mL/minute. Furthermore, there are no pharmacokinetic studies available for severe kidney impairment in patients with a CrCl <30 mL/minute.
[lab data]
2025-06-06 Anti-HBc Reactive
2025-06-06 Anti-HBc Value 6.04 S/CO
2025-06-06 HBsAg Nonreactive
2025-06-06 HBsAg Value 0.33 S/CO
2025-06-06 Anti-HCV Nonreactive
2025-06-06 Anti-HCV Value 0.21 S/CO
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[immunochemotherapy]
This 50-year-old man with a background of alcohol-related cirrhosis (Child B), hepatic encephalopathy, and prior hepatocellular carcinoma has recurrent esophageal squamous cell carcinoma (T2N1Mx) following CCRT in late 2024. He initiated second-line immunochemotherapy with Nivolumab + PF2 on 2025-06-06. He remains clinically stable with preserved ECOG 1, no overt hepatic encephalopathy, mild thrombocytopenia, and preserved renal and electrolyte profiles. Recent vital signs and labs (2025-07-01 and 2025-07-03) are stable.
Problem 1. Recurrent esophageal squamous cell carcinoma, stage T2N1Mx
Problem 2. Chronic liver cirrhosis with encephalopathy risk
Problem 3. Thrombocytopenia with risk of bleeding
Problem 4. Electrolyte and renal function under cisplatin-based chemotherapy (below not posted)
Problem 5. Blood pressure elevation and cardiovascular monitoring
This 50-year-old man with a history of alcohol-related cirrhosis (Child B), hepatic encephalopathy, and bilateral hepatocellular carcinoma (post-TACE and HAIC), was diagnosed with moderately differentiated squamous cell carcinoma of the middle third esophagus, stage cT2N2M0. He previously received CCRT (PF1) with radiotherapy from 2024-10-15 to 2024-11-22. Recurrent esophageal malignancy was pathologically confirmed (EGD 2025-03-31, biopsy 2025-04-01, EUS 2025-04-07), restaged as T2N1Mx, and not amenable to further surgery or radiotherapy. Current management includes immunochemotherapy with Nivolumab + PF2 (2025-06-06). He remains ECOG 1, afebrile, with stable vitals and lab parameters except for chronic thrombocytopenia and fluctuating hyperammonemia, now improved (157 → 69 µmol/L from 2025-06-06 to 2025-06-09). Liver function is relatively preserved.
Problem 1. Recurrent esophageal squamous cell carcinoma, stage cT2N1Mx
Problem 2. Chronic hepatic encephalopathy with cirrhosis (Child B)
Problem 3. Chronic thrombocytopenia
Problem 4. Renal function and electrolyte monitoring under chemotherapy
Problem 5. Nutritional and general performance status
[lab data]
2025-02-25 BCR/abl (BM) (qual) Undetectable
2025-02-24 FLT3/ITD mutation (BM) Undetectable
2025-02-24 JAK2 gene mutation (quan) 0.00 %
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
This 69-year-old woman with MDS RAEB-2 continues to show persistent pancytopenia and progressive increase in peripheral blasts (5.1% on 2025-07-02), despite ongoing Vidaza (azacitidine) therapy since 2023-12. She remains transfusion-dependent for both RBCs and platelets, with recurrent bleeding episodes including gum bleeding. Chronic thrombocytopenia (PLT 2–7 x10^3/uL), anemia (HGB 6.6–8.7 g/dL), and rising ferritin (>4000 ng/mL) reflect disease progression and transfusion-related iron overload. Renal function fluctuates around CKD stage 3, with eGFR declining from 84.01 (2025-06-09) to 52.34 (2025-07-02). Bilateral pleural effusions persist without respiratory compromise. Current ECOG PS is 2. Supportive care includes transfusions, chelation (Jadenu), and symptomatic agents. Prognosis remains guarded.
Problem 1. Refractory anemia with excess blasts (RAEB-2)
Problem 2. Chronic transfusion-dependent thrombocytopenia
Problem 3. Iron overload
Problem 4. Renal insufficiency (CKD stage 3)
Problem 5. Bilateral pleural effusion
Problem 6. Normocytic anemia (not posted)
Problem 1. Acute-on-chronic anemia
Problem 2. Thrombocytopenia with mucosal bleeding
Problem 3. Leukemic transformation of MDS (RAEB-2 with persistent blasts)
Problem 4. Pleural effusion and respiratory monitoring
Problem 5. Renal function and electrolyte balance
Problem 6. Transfusion-related iron overload
This 68-year-old woman with myelodysplastic syndrome with excess blasts-2 (MDS-EB2) has undergone leukemic transformation into acute myeloid leukemia (AML), confirmed by bone marrow (98% cellularity with 30% CD34+ and CD117+ blasts on 2025-02-18) and lymph node biopsy (2025-02-20). Despite ongoing Vidaza (azacitidine) chemotherapy, she continues to exhibit persistent anemia, severe thrombocytopenia, and fluctuating leukocytosis with circulating blasts (up to 7.0% on 2025-05-12). She is also transfusion-dependent and demonstrates signs of iron overload (ferritin >4000 ng/mL since 2025-03), along with recurrent pleural effusions and mild fluid overload likely related to treatment and/or disease. Her cardiac function remains preserved (LVEF 78% on TEE 2025-04-17), though she exhibits aortic stenosis. She is currently ECOG PS 1, afebrile, and stable on supportive care.
Problem 1. Acute Myeloid Leukemia (secondary to MDS-EB2)
Problem 2. Severe Thrombocytopenia
Problem 3. Transfusion-Dependent Anemia
Problem 4. Iron Overload
Problem 5. Electrolyte Abnormalities: Hypokalemia
Problem 6. Bilateral Pleural Effusions (AML-related) (below not posted)
Problem 7. Cardiovascular Status
Problem 1. AML Secondary to MDS with Persistent Cytopenia
Problem 2. Malignant Pleural Effusion
Problem 3. Persistent Hypokalemia
Problem 4. Hemodynamic and Vital Sign Stability
Problem 5. Severe Thrombocytopenia
Problem 6. Chronic Iron Overload
Patient Review
Problem 1. Acute Myelogenous Leukemia (AML) Transformation from MDS
Problem 2. Persistent Severe Cytopenia (Anemia & Thrombocytopenia)
Problem 3. Extensive Lymphadenopathy & Splenomegaly – Suspected Extramedullary AML vs. Lymphoma Transformation
Problem 4. Bilateral Pleural Effusions & Minimal Ascites – Suspected Malignant or Inflammatory Etiology
Problem 5. Splenic Lesions – Possible Myeloid Sarcoma vs. Infiltrative Disease
Conclusion & Next Steps (not posted)
[Treatment for AML-MDS and de novo AML] (not posted)
The treatment for acute myeloid leukemia (AML) arising from myelodysplastic syndromes (AML-MDS) and de novo AML should generally be different due to key biological, clinical, and prognostic differences between the two entities.
Reasons for Treatment Differences:
Conclusion:
[adapting Vidaza (azacitidine) dosing in MDS treatment]
The patient, weighing 59kg with a height of 159cm, has a BMI of 23.3 kg/m2 and a BSA of 1.61 m2.
For MDS, azacitidine administration is typically recommended as follows:
Alternative dosing schedules include:
For this patient, Vidaza (azacitidine) was administered at an approximate dosage of 62 mg/m2/day (100mg/day) for 3 or 2 days, with intervals varying from 1 to 3 weeks. This represents a lower dosage (mg/kg/day), shorter duration (reduced from the recommended 7 or 5 days to 3 or 2 days), and a more frequent dosing schedule (shorter cycle intervals). Deviating from the standard recommended regimen could potentially yield different therapeutic outcomes from the original regimen’s design.
[transfusion-dependent patient: elevated ferritin suggests iron overload, deferasirox considered]
Given the patient’s history of receiving multiple blood transfusions monthly for an extended period, lab data from 2023-12-13 revealed a serum ferritin level of 2261.8 ng/mL, suggesting the possibility of iron overload. Jadenu (deferasirox), the sole iron chelator available at this institution, could be considered as a treatment option. As of 2024-02-16, the patient’s ALT level was 14 U/L and the eGFR was 60.88 ml/min/1.73m^2, indicating no contraindications for using this medication. Jadenu treatment may be initiated at a dosage of 14 mg/kg daily, with subsequent dose adjustments every 3 to 6 months, depending on serum ferritin levels.
Jadenu (deferasirox) at a daily dose of 360 mg has been administered since Dec 2023. This dosage is below the suggested level of 14 mg/kg for a 59 kg individual, which would amount to 826 mg daily.
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
[note]
Non-Hodgkin lymphoma ESHAP (etoposide methylprednisolone cytarabine cisplatin) - 2025-06-02 - https://www.eviq.org.au/haematology-and-bmt/lymphoma/other-b-cell-lymphoma/124-eshap-etoposide-methylprednisolone-cytarabine
Initial treatment of peripheral T cell lymphoma - INDUCTION THERAPY - 2023-11-24 - https://www.uptodate.com/contents/initial-treatment-of-peripheral-t-cell-lymphoma
As of 2025-07-03 (Day +21 post-haploidentical allo-PBSCT), the patient shows stable clinical status with no signs of active GVHD or infection. Neutrophil engraftment has occurred (WBC 8.71 ×10³/uL on 2025-07-02), and oral intake is improving. Diarrhea has resolved; only mild abdominal discomfort remains. Immunosuppression continues with IV ciclosporin and oral mycophenolate mofetil. Letermovir and valacyclovir are used for CMV/HSV prophylaxis. Zinc level is within upper-normal limits (1011 µg/L on 2025-07-02). Nutritional status is monitored, with gradual tapering off of TPN considered.
Problem 1. Post-allo PBSCT Immune Reconstitution
Problem 2. Gastrointestinal Symptoms (Mild Abd Pain and Previous Diarrhea) (not posted)
Problem 3. Anemia and Thrombocytopenia
Problem 4. Infection Prophylaxis and Viral Reactivation
This 25-year-old male is on Day +15 post-haploidentical allo-PBSCT for recurrent CD30-negative peripheral T-cell lymphoma. As of 2025-06-27, he demonstrates evidence of neutrophil engraftment (WBC 4.65 x10^3/uL, Neutrophils 85.0%) and improving mucositis (Grade 1), without ongoing fever or respiratory distress. Ongoing challenges include thrombocytopenia (PLT 56 x10^3/uL), persistent anemia (HGB 9.0 g/dL), immunosuppression monitoring, and TPN support due to prior poor oral intake. CMV is being prophylactically managed with Brand Name (letermovir), and active infection appears absent.
Problem 1. Post-allo-PBSCT Immunologic Recovery
Problem 2. Nutritional Support and TPN Management
Problem 3. Electrolyte Imbalances (Mg, Ca, P) (not posted)
Problem 4. Immunosuppression and GVHD Prophylaxis
Problem 5. Infection Prophylaxis and Surveillance (Including CMV)
Key Insight / Summary
Problem 1. Profound Neutropenia with Sepsis Risk
Problem 2. Persistent Thrombocytopenia and Anemia
Problem 3. Gastrointestinal Mucositis and Diarrhea
Problem 4. Nutritional Support and Weight Loss
Problem 5. Immunosuppression Post-allo PBSCT
Problem 6. CMV Prophylaxis Post-Allo PBSCT
[Recommendation with Critical Considerations for Prevymis (letermovir) tube-feeding]
If absolutely no alternatives exist (oral pellets or IV formulation unavailable), SSM may be considered as a last resort, but with these conditions:
Step-by-Step SSM Protocol (Based on Limited Evidence). If proceeding despite risks:
Critical Precautions:
Risks vs. Alternatives
| Factor | SSM with Tablets | Official Alternatives |
|---|---|---|
| Approval | Not approved14 | Pellets/IV are approved1 |
| Efficacy Support | Limited case data only3 | Full clinical trial data1 |
| Safety Profile | Unknown bioavailability1 | Established1 |
| Recommendation | Last-resort only | First choice |
Strong Disclaimer
The patient is a 25-year-old male with recurrent CD30-negative, EBV-positive stage IV peripheral T-cell lymphoma, status post haploidentical peripheral blood stem cell transplant (PBSCT) from his sister on 2025-06-12 (Day 0). Conditioning included fludarabine, busulfan, ATG, and TBI. He is now at Day 4 post-transplant (2025-06-16), presenting with febrile neutropenia, thrombocytopenia, and gastrointestinal intolerance. Despite prophylactic antimicrobial coverage and post-transplant cyclophosphamide (Endoxan), his clinical status is complicated by high-grade fever (38.6°C), tachycardia (PR 146), hypoxia (SpO₂ 86% on room air), and rising procalcitonin (PCT 9.91 ng/mL on 2025-06-16), suggesting ongoing or worsening sepsis. Culture data are inconclusive or show likely contaminants. Supportive care includes PPN, mesna, G-CSF, and immunosuppressants (MMF, ciclosporin). Platelets and WBC remain critically low. (not posted)
Problem 1. Febrile neutropenia with respiratory compromise
Problem 2. Pancytopenia post-allo PBSCT
Problem 3. Hepatic enzyme fluctuation and renal function
Problem 4. Nutritional insufficiency with GI intolerance
[Interprofessional Practice and Family Meeting Note]
Date/Time: 2025-06-04, 10:00–11:15 Location: 11A Ward Conference Room
Chair: Dr. Gao Participants (Family): Patient, patient’s mother, eldest sister, second sister, paternal eldest uncle Participants (Medical Team): Attending physician Dr. Gao, nurse practitioner Ms. Chen, pharmacist, dietitian, psychologist, social worker
Meeting Summary:
Dr. Gao provided the patient and family with a detailed explanation of the disease course and prior treatments. The pros and cons of allogeneic transplantation were thoroughly discussed. Dr. Gao also cited literature indicating a long-term survival rate of approximately 40%, with another study showing survival curves stratified by different IPI scores. Nurse practitioner Ms. Chen inquired whether the patient had any hesitation regarding nasogastric tube placement if necessary; the patient expressed willingness to undergo NG tube placement if needed.
[Bedside Visit]
Time: 2025-06-04, 11:40
At the time of the visit, the patient’s mother had gone downstairs for lunch. The patient and his eldest sister were present in the room. I emphasized the importance of infection prevention and avoidance, as well as the critical role of supporting hematopoietic recovery during this period. Both the patient and family appeared optimistic and expressed no specific medication-related concerns during the visit.
This is a 25-year-old male with CD30-negative relapsed peripheral T-cell lymphoma (PTCL), stage IV, EBV-positive, Ki-67 index 50%, initially treated with CHOEP (2023-09 to 2024-01), then with ESHAP (from 2025-03), and currently receiving Folotyn (pralatrexate) weekly since 2025-04-23. Most recent PET (2025-05-26) demonstrates partial to complete metabolic response. He is planned for haploidentical allogeneic PBSCT on 2025-06-12. Current vitals and labs are stable. Liver enzymes, previously elevated, are improving (ALT 105 U/L on 2025-06-02 vs. peak 315 U/L on 2025-05-13). CBC parameters have also stabilized, and electrolytes, renal function, and coagulation are within acceptable range.
Problem 1. Relapsed CD30-negative Peripheral T-cell Lymphoma (Stage IV, EBV+, Ki-67 50%)
Problem 2. Hepatocellular enzyme elevation (ALT-dominant hepatopathy)
Problem 3. Electrolyte and Renal Function Status
Problem 4. Seizure Prophylaxis
Problem 5. Preparation for Allogeneic Transplant
[Phenytoin vs. Levetiracetam for Seizure Prophylaxis in Busulfan-Based Allo-PBSCT]
| Aspect | Phenytoin | Levetiracetam |
|---|---|---|
| Mechanism | Blocks voltage-gated Na⁺ channels | Binds to synaptic vesicle protein SV2A, modulates NT release |
| Effect | Stabilizes neuronal membranes, suppresses seizure spread | Broad-spectrum anticonvulsant |
| Parameter | Phenytoin | Levetiracetam |
|---|---|---|
| Adult Dose | 1.25 mg/kg IV/PO every 6 hrs | 500–1000 mg IV/PO twice daily |
| Pediatric Dose | 1.25 mg/kg IV/PO every 6 hrs | 10–20 mg/kg/day IV/PO divided q12h |
| Duration | Start 1–2 days pre-busulfan; continue until 24–48 hrs post-last dose | Start 6–24 hrs pre-busulfan; continue 24–48 hrs post-last dose |
| Loading Dose | Not used in busulfan protocols | Not required |
| TDM Required | Yes (target: 10–20 µg/mL) | No |
| Aspect | Phenytoin | Levetiracetam |
|---|---|---|
| Half-life | 7–42 hours (nonlinear kinetics) | 6–8 hours |
| Metabolism | Hepatic (CYP2C9, CYP2C19) | Minimal hepatic metabolism |
| Elimination | Dose-dependent hepatic clearance | Renal (unchanged drug) |
| Key Interaction | Induces CYP3A4 → ↑ busulfan clearance by 15–20% | No CYP interactions → preserves busulfan PK |
| Aspect | Phenytoin | Levetiracetam |
|---|---|---|
| Busulfan Interaction | Clinically significant: Alters busulfan levels | None |
| CYP Induction | Strong inducer (CYP3A4/2C9/UGT) | None |
| Antifungal DDIs | Contraindicated with azoles (e.g., voriconazole) | Safe |
| Other DDIs | Warfarin, calcineurin inhibitors, chemotherapy | Minimal |
| Aspect | Phenytoin | Levetiracetam |
|---|---|---|
| CNS Effects | Nystagmus, ataxia, cerebellar toxicity | Fatigue, irritability (rare) |
| Rash | Risk of SJS/TEN | Rare |
| Hepatotoxicity | Dose-dependent (e.g., elevated LFTs) | None |
| Monitoring | LFTs, CBC, albumin, drug levels | None |
| Metric | Phenytoin | Levetiracetam |
|---|---|---|
| Seizure Prevention | 9.3% failure rate | 100% efficacy in studies |
| Pediatric Safety | 4% seizure risk | 0% seizure risk |
| Source | Phenytoin | Levetiracetam |
|---|---|---|
| EBMT | Not recommended | Preferred agent |
| Institutional Use | Legacy protocols only | First-line in >90% of centers (2025 data) |
| Scenario | Preferred Agent | Rationale |
|---|---|---|
| All allo-PBSCT patients | Levetiracetam | Superior efficacy, no interactions, better safety |
| Hepatic impairment | Levetiracetam | No hepatic metabolism |
| Pediatrics | Levetiracetam | 0% seizure risk vs. phenytoin’s 4% |
| Phenytoin Use | Avoid unless contraindications to levetiracetam | Obsolete due to inefficacy and toxicity risks |
A point-by-point comparison of phenytoin and levetiracetam for busulfan-induced seizure prophylaxis in allo-PBSCT, supported by evidence:
Final Recommendation
Levetiracetam is the first-line choice for busulfan-induced seizure prophylaxis in allo-PBSCT, supported by:
Phenytoin should be avoided except in rare cases of levetiracetam intolerance.
References:
1 https://pmc.ncbi.nlm.nih.gov/articles/PMC6132870/ 2 https://pubmed.ncbi.nlm.nih.gov/36843563/ 3 https://pubmed.ncbi.nlm.nih.gov/36071908/ 4 https://pubmed.ncbi.nlm.nih.gov/32026356/ 5 https://pubmed.ncbi.nlm.nih.gov/33894096/ 6 https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2022.928550/full 7 https://core.ac.uk/download/pdf/82426316.pdf [8] https://bmtctn.net/system/files/0901_MDS_AML_v5.pdf [9] https://www.sciencedirect.com/science/article/pii/S1083879119301508 [10] https://www.albertahealthservices.ca/assets/info/hp/cancer/if-hp-cancer-guide-bmt-manual.pdf
[reconciliation]
Lab results on 2024-01-25 indicated normal liver and kidney function tests, with serum uric acid levels at 9.0 mg/dL, suggesting hyperuricemia. This condition is being managed with Feburic (febuxostat), and there are no discrepancies in medication.
[lab data]
2025-01-15 HLA A-high 02:07
2025-01-15 HLA A-high 11:01
2025-01-15 HLA B-high 46:01
2025-01-15 HLA B-high 55:02
2025-01-15 HLA C-high 01:02
2025-01-15 HLA C-high -
2025-01-15 HLA DQ-high 03:01
2025-01-15 HLA DQ-high 03:03
2025-01-15 HLA DR-high 09:01
2025-01-15 HLA DR-high 12:02
2024-12-03 HBsAg (NM) Negative
2024-12-03 HBsAg Value (NM) 0.410
2024-12-03 Anti-HCV (NM) Negative
2024-12-03 Anti-HCV Value (NM) 0.040
2024-12-03 Anti-HBs (NM) Negative
2024-12-03 Anti-HBs value (NM) <2.000 mIU/mL
2024-12-03 Anti-HBc (NM) Negative
2024-12-03 Anti-HBc Value (NM) 1.340
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
2025-06-11 - methotrexate 15mg/m2 23mg NS 250mL 0.5hr D1 + methotrexate 10mg/m2 15mg NS 250mL 0.5hr D3,6,11
2025-06-04 - fludarabine 30mg/m2 45mg NS 250mL 1hr D1-5 + melphalan 70mg/m2 100mg NS 500mL 1hr D4-5
2024-04-15 - Vidaza (azacitidine) 75mg/m2 113mg SC D1-7
2024-03-13 - Vidaza (azacitidine) 75mg/m2 113mg SC D1-7
2024-02-11 - Vidaza (azacitidine) 75mg/m2 114mg SC D1-7
2024-01-02 - Vidaza (azacitidine) 75mg/m2 114mg SC D1-7
The patient is a post-allogeneic HSCT recipient for myelodysplastic syndrome with excess blasts II and complex cytogenetics, currently around Day +23 post-transplant (since conditioning with ATG on 2025-06-05 and methotrexate maintenance began 2025-06-11). Hematologic recovery is evident by marked leukocytosis (WBC 0.12 → 20.49 x10³/uL from 2025-06-26 to 2025-07-02), suggesting engraftment. Fever resolved, mucositis and diarrhea improved, and PCT remains low (0.16 ng/mL on 2025-07-02). Persistent anemia and thrombocytopenia remain. No CMV reactivation noted. Renal and liver function are preserved.
Problem 1. Post-HSCT engraftment and hematologic recovery
Problem 2. Infection status and anti-infective management
Problem 3. Immunosuppression monitoring
Problem 4. Cytopenias: persistent thrombocytopenia and anemia
Problem 5. CMV infection prophylaxis consideration
Key Insight / Summary
Problem 1. Myelodysplastic Syndrome (RAEB-II) Post-Allo-HSCT
Problem 2. Infection Risk and Management (Neutropenic Fever)
Problem 3. Persistent Pancytopenia
Problem 4. Nutrition and Diarrhea (not posted)
Problem 5. Electrolyte and Renal Function Monitoring (not posted)
Problem 6. Antiviral Prophylaxis: CMV
Problem 7. CMV prophylaxis after allo-HSCT
Objective
Assessment
According to NHI rule 10.7.12, this patient meets all eligibility criteria for letermovir use:
The absence of Prevymis during this early vulnerable period may increase CMV reactivation risk.
Recommendation
Initiate Prevymis (letermovir) as CMV prophylaxis pending prior authorization.
Monitor weekly CMV PCR assays to assess for breakthrough viremia.
Re-evaluate drug interactions, especially with cyclosporin (dose adjustment not required but close monitoring needed).
a “CMV viral load: Target Not Detected” on 2025-06-25 is not a sufficient reason to omit anti-CMV prophylaxis in this patient.
Conclusion:
The patient is in the post-conditioning phase following allogeneic PBSCT for MDS-RAEB-II with complex cytogenetics. As of 2025-06-23, he remains severely pancytopenic (WBC 0.03, PLT 19, HGB 8.9), with ongoing grade 2 oral mucositis and persistent candidiasis. No evidence of invasive fungal disease or active bacterial infection is found (PCT 0.05 ng/mL on 2025-06-16, stable vitals). Supportive care includes broad-spectrum antimicrobials (meropenem, teicoplanin, micafungin), G-CSF, PPN, and ciclosporin. Renal and hepatic function are stable. Despite mucositis and intermittent diarrhea, his general status remains ECOG 1.
Problem 1. Persistent Severe Pancytopenia Post-Allo PBSCT
Problem 2. Febrile Neutropenia with Broad-Spectrum Antimicrobial Use
Problem 3. Mucositis and Oral Candidiasis
Problem 4. Electrolyte and Nutritional Support in the Setting of Diarrhea
Problem 5. Immunosuppressive Therapy with Ciclosporin
Problem 6. CMV prophylaxis post-allo-HSCT: consider need for Prevymis (letermovir)
The 69-year-old male with myelodysplastic syndrome with excess blasts II and complex cytogenetics has completed conditioning (fludarabine, melphalan, ATG), received methotrexate post-transplant (2025-06-11 D+1), and underwent allo-PBSCT on 2025-06-10. Febrile neutropenia and elevated PCT (11.47 ng/mL on 2025-06-09) prompted broad-spectrum antibiotics and antifungal coverage. Diarrhea developed, requiring parenteral nutrition. As of 2025-06-16, he remains afebrile with ECOG 1 and no new mucosal lesions; candidiasis is present. WBC remains at 0.02 ×10³/uL with 0% neutrophils; Procalcitonin normalized to 0.05 ng/mL. Renal and liver functions are preserved.
Problem 1. Profound neutropenia post-allo-PBSCT
Problem 2. Recent sepsis with successful microbial control
Problem 3. Diarrhea and nutritional support
Problem 4. Mucositis and candidiasis
Problem 5. Hepatic function alteration (possible DILI) (not posted)
Patient Summary
Problem 1. Febrile neutropenia and sepsis suspicion
Problem 2. Pancytopenia post-conditioning (pre-transplant Day -1)
Problem 3. Electrolyte and renal function monitoring under chemotherapy
Active Medication Review
Problem 1. Transfusion-dependent anemia and thrombocytopenia
Problem 2. Suboptimal hematologic response to Vidaza (azacitidine)
Problem 3. Iron overload secondary to transfusion
Problem 4. Stable renal and hepatic function
Problem 5. Disease status: MDS-IB2 without AML transformation
[Anemia and Thrombocytopenia Evaluation]
Objective Findings
Assessment
Recommendations
[Evaluation of Vidaza (azacitidine) Treatment Effect]
Objective Findings
Assessment of Vidaza Efficacy
Recommendations
Final Summary
[Evaluation of Treatment Alignment with NCCN Guidelines for Myelodysplastic Syndromes (MDS)] (not posted)
Does the treatment align with NCCN Guidelines?
Why does it align?
Appropriate for High-Risk MDS: The NCCN guidelines recommend hypomethylating agents (HMAs) such as azacitidine or decitabine as a standard first-line therapy for higher-risk MDS, particularly for patients ineligible for hematopoietic stem cell transplantation (HCT).
Standard Dosing: The dosage and schedule of azacitidine 75 mg/m² SC D1-7 Q4W is consistent with NCCN recommendations.
Alternative to HCT in High-Risk Cases: Allogeneic hematopoietic cell transplantation (HCT) is the only curative therapy but is typically reserved for younger, fit patients. Given the patient’s cytogenetic profile (complex karyotype: -5, -7, -12, -17, der(20)t(17;20)), high-risk status, and the use of azacitidine, the treatment plan is within guideline-based options.
Consideration of Emerging Therapy: The guidelines also mention combination therapy with azacitidine + venetoclax for patients with higher-risk MDS. While venetoclax is not currently included in this patient’s regimen, its use is suggested in patients with refractory disease or high blast counts.
Additional Considerations:
Conclusion
[Cytogenetic Analysis]
Cytogenetic Analysis Interpretation:
This cytogenetic profile provides critical prognostic and therapeutic insights:
Final Summary
[Patient Summary]
The patient is a 69-year-old male with myelodysplastic syndrome (MDS) with refractory anemia and excess of blasts II. Diagnosed with a complex cytogenetic profile (3843,XY,-5,-7,-12,der(14)t(11;14)(q13;p11.2),-17,-17,der(20)t(17;20)(q11.2;q11.2),+12mar[cp8]∕46,XY1) on 2024-12-09, he has been experiencing progressive pancytopenia with macrocytic anemia since 2024-11-29, requiring frequent transfusions. His treatment was initiated with Vidaza (azacitidine) on 2025-01-02 for a planned 7-day regimen monthly for 4 months. Significant findings include pancytopenia with blasts (~15% on bone marrow biopsy, 2024-12-09) and stable vital signs. Key challenges include cytopenias and a complex karyotype with a p53 mutation, both of which carry a poor prognosis.
[MDS Comments]
Problem: Myelodysplastic Syndrome with Refractory Anemia and Excess of Blasts II (MDS-IB2)
[Evaluation for Anemia and Thrombocytopenia]
Objective
Assessment
Recommendations
[exam finding]
[MedRec]
[exam finding]
[MedRec]
[consultation]
[Subjective]
medication adherence and perception
symptom status
[Objective]
medication list
vital signs and labs
[Assessment]
heart failure with reduced ejection fraction (HFrEF)
gout and uric acid control
renal protection and monitoring
patient engagement and adherence
[Plan / Recommendation]
optimize heart failure pharmacotherapy
renal and electrolyte monitoring
gout management
lipid and vascular protection
education and follow-up
This 55-year-old male was admitted on 2025-06-19 with exertional dyspnea and elevated BP (181/137 mmHg), diagnosed with acute decompensated heart failure with reduced ejection fraction (HFrEF, LVEF 27%), dilated cardiomyopathy, and suspected ischemic cardiomyopathy. Imaging revealed global LV hypokinesia, moderate-to-large pericardial effusion, and grade III diastolic dysfunction. Serial hsTnI were mildly elevated; NT-proBNP peaked at 5378.9 pg/mL. His clinical course improved after IV diuretics and guideline-directed medical therapy (ARNI, beta-blocker, SGLT2 inhibitor, MRA). He was discharged on 2025-06-27 and was stable at follow-up on 2025-07-01 with NYHA class III symptoms improving. Issues of note include moderate LV systolic dysfunction, pulmonary hypertension, gout flare, CKD stage 3, mild transaminitis, and hyperuricemia.
Problem 1. Heart failure with reduced ejection fraction (HFrEF)
Problem 2. Ischemic heart disease / prior infarction
Problem 3. Moderate to large pericardial effusion
Problem 4. Chronic kidney disease (CKD) stage 3
Problem 5. Gouty arthritis flare
Problem 6. Electrolyte and acid-base balance
GDMT stands for Guideline-Directed Medical Therapy.
In the context of heart failure, GDMT refers to the use of medications and interventions that are recommended by clinical practice guidelines (such as those from the American College of Cardiology [ACC], American Heart Association [AHA], and European Society of Cardiology [ESC]) based on strong evidence to improve outcomes in patients.
For HFrEF (Heart Failure with Reduced Ejection Fraction), GDMT typically includes:
These therapies have been shown to reduce mortality and hospitalizations in patients with HFrEF.
[exam finding]
[MedRec]
[consultation]
[Subjective]
Medication use and concerns reported by family
Follow-up discussion reminders suggested for next physician visit
[Objective]
Current medication list
Relevant labs and findings
[Assessment]
Potential drug-drug interaction: esomeprazole and clopidogrel
Inadequate thyroid replacement therapy
Suboptimal glycemic control
[Plan / Recommendation]
Address possible clopidogrel-PPI interaction
Reassess levothyroxine dose
Evaluate need for glucose-lowering therapy
Monitor for adverse effects and adherence
Document communication
This is a 74-year-old man with a complex cardiovascular and systemic background, notably:
Problem 1. Coronary artery disease with recent NSTEMI and PCI
Problem 2. Heart failure with reduced ejection fraction (HFrEF)
Problem 3. Chronic kidney disease stage 3b
Problem 4. Bradyarrhythmia and PVCs
Problem 5. Hypothyroidism (post-subtotal thyroidectomy)
Problem 6. Dyslipidemia
[exam finding]
[MedRec]
[consultation]
This is a 62-year-old male with synchronous dual malignancies: (1) stage IIIA left lower lobe lung adenocarcinoma (T4N0M0) without actionable mutations or PD-L1 expression, and (2) early-stage (cT1N0M0) nasopharyngeal non-keratinizing carcinoma (WHO type II), both biopsy-confirmed. He also has end-stage renal disease (ESRD) on thrice-weekly hemodialysis (QW135), long-standing type 2 diabetes with chronic foot ulcer, and ischemic heart disease. Based on the 2025-06-13 radiation oncology evaluation, the treatment strategy is concurrent chemoradiotherapy (CCRT) for nasopharyngeal carcinoma and planned neoadjuvant chemotherapy ± pembrolizumab for lung cancer following port-A insertion. The patient is clinically stable (ECOG 1), with preserved LV function and manageable comorbidities.
Problem 1. Stage IIIA left lower lobe lung adenocarcinoma (T4N0M0)
Problem 2. Stage I nasopharyngeal carcinoma (non-keratinizing, WHO-2A)
Problem 3. End-stage renal disease (on hemodialysis QW135)
Problem 4. Type 2 diabetes mellitus with chronic foot ulcer
Problem 5. Hypertension and ischemic heart disease
[A detailed analysis on the timing of hemodialysis after cisplatin infusion, grounded in current evidence-based strategies] (not posted)
Timing of Hemodialysis Post-Cisplatin
Hydration and Nephroprotection
Recommendation Summary for ESRD & Cisplatin Patient
Clinical Implication for This Patient
Ref:
[A detailed analysis on whether “ESRD reduces insulin clearance,” with support from academic sources]
Mechanistic Basis
Clinical Evidence
Multiple reviews indicate that exogenous insulin clearance is diminished in advanced renal failure, with reduced dosage needs and prolonged insulin effect 3.
One source states: “In some patients with advanced insulin-dependent T2DM with ESRD, the insulin requirement becomes markedly reduced, in part due to decreased insulin clearance.” 3
A 2021 consensus noted kidneys responsible for 30–80 % of insulin clearance; decreased GFR prolongs insulin half-life 4.
Summary
Clinical Implication
Ref:
[exam finding]
[MedRec]
[consultation]
[immunochemotherapy]
This is a 72-year-old woman with small cell B-cell lymphoma (likely marginal zone subtype), Lugano stage IV involving lymph nodes and bone marrow. Since diagnosis via bone marrow biopsy on 2024-01-02, she has received R-COP chemotherapy (C1–C5) with good tolerance. Imaging (CT 2025-06-20) shows partial response with regression of lymphadenopathy. Concurrent medical issues include paroxysmal atrial fibrillation (s/p ablation on 2025-01-09), CKD stage 3, normocytic anemia, past pulmonary edema with preserved EF, and intermittent eczema.
She began R-COP on 2025-07-01 this hospital stay under stable hemodynamic and biochemical status. Recent blood and metabolic panels suggest partial hematologic improvement, stable renal and liver function, and resolution of previously elevated inflammatory parameters. No fever, edema, or active infection is observed. She remains ECOG PS 1.
Problem 1. Small B-cell lymphoma, Lugano stage IV
Problem 2. Anemia (normocytic, chronic)
Problem 3. Chronic kidney disease (stage 3)
Problem 4. Cardiovascular comorbidity: paroxysmal atrial fibrillation, HFpEF
Problem 5. Dermatologic condition: eczema (not posted)
This is a 72-year-old woman with small B-cell lymphoma (likely marginal zone lymphoma), Lugano stage IV with bone marrow involvement, undergoing immunochemotherapy with R-COP regimen. She also has a history of paroxysmal atrial fibrillation (s/p 4PVI and CTI ablation on 2025-01-09), heart failure with preserved ejection fraction (HFpEF), chronic kidney disease (CKD) stage 3, moderate to severe mitral regurgitation, and normocytic anemia.
Despite stable coronary arteries (CAG 2024-05-03), she experienced recurrent pulmonary edema (CXR 2025-01-25) and rising BUN/Cr with anemia progression. She recently received R-COP (2025-03-31) under a stable but borderline condition. Labs show worsening anemia, persistent leukocytosis, and rising inflammatory markers (CRP, PCT). Imaging shows stationary paraaortic lymphadenopathy and newly noted axillary and cervical LNs (CT 2025-02-10).
Problem 1. Hematologic Malignancy - Small B-cell Lymphoma, Lugano Stage IV
Problem 2. Normocytic Anemia
Problem 3. Heart Failure and Arrhythmia (AF, MR, HFpEF)
Problem 4. Chronic Kidney Disease, Stage 3 (below not posted)
Problem 5. Inflammatory and Infectious Monitoring
[exam finding]
[MedRec]
[surgical operation]
[radiotherapy]
[immunochemotherapy]
[note]
Systemic therapy regimens for locally advanced, potentially resectable gastric or gastro-esophageal junction adenocarcinoma: Perioperative docetaxel, oxaliplatin, fluorouracil, and leucovorin (FLOT4) - 2025-06-11 - https://www.uptodate.com/contents/image?imageKey=ONC%2F120512
Cycle length: 14 days.
Duration of therapy:
Regimen
The patient is a 69-year-old male with dual advanced malignancies: (1) rectal adenocarcinoma with liver metastasis (cT3N2bM1, stage IVb) and (2) prostate adenocarcinoma, Gleason 5+5 with bilateral ureteral invasion and bone metastasis (cT4N1M1b, stage IVb). He is undergoing biweekly Avastin + FLOT chemotherapy (C3D1 on 2025-07-01), with supportive care for chronic kidney disease (eGFR 30.4 mL/min/1.73m²), anemia (HGB 8.6 g/dL on 2025-06-30), hypomagnesemia (Mg 1.7 mg/dL), and persistent dysuria with bilateral PCN in place. Pain and appetite issues are mild. Chemotherapy tolerance remains acceptable (G1-G2 toxicities). Leucovorin was correctly added back into the FLOT protocol on 2025-07-01.
Problem 1. Renal Dysfunction with ESRD/CKD Progression
Problem 2. Anemia (Multifactorial: Marrow suppression, CKD, Cancer)
Problem 3. Active Cancer Therapy: Rectal Adenocarcinoma with Liver Metastasis
Problem 4. Prostate Adenocarcinoma with Bilateral Ureteral Invasion and Bone Metastasis
Problem 5. Infection Risk and Linezolid Use
Problem 6. Hypomagnesemia
Problem 7. Nutritional Support and Albumin
The 68-year-old male with dual primary malignancies—prostate adenocarcinoma (Gleason 5+5, cT4N1M1b) and rectal adenocarcinoma (cT3N2bM1) - is undergoing Avastin + FLOT chemotherapy since 2025-05-16. He also has chronic kidney disease secondary to obstructive uropathy and is complicated by recurrent urinary tract infections with bilateral percutaneous nephrostomies (PCNs) in place.
As of 2025-06-11, he tolerated chemotherapy without acute toxicity, though residual infection indicators and persistent anemia are noted. Chemotherapy continues without leucovorin; nephrology and infectious disease consultations are active.
Problem 1. Renal dysfunction and obstructive uropathy
Problem 2. Recurrent urinary tract infections (UTIs)
Problem 3. Chemotherapy regimen and response
Problem 4. Anemia of chronic disease and chemotherapy
Problem 5. Electrolyte and acid-base disturbance
This 68-year-old male with dual advanced malignancies—prostate adenocarcinoma (Gleason 5+5, cT4N1M1b) and rectal adenocarcinoma (cT3N2bM1) - presents with progressive disease complicated by bilateral obstructive uropathy, chronic kidney disease (Cr 1.79 mg/dL, eGFR 40.3 mL/min/1.73m² on 2025-05-15), anemia (Hb 6.9 g/dL), ongoing urinary tract infection (UTI) with pyuria and bacteriuria, and persistent inflammation (CRP 17.8 mg/dL on 2025-05-05, Procalcitonin 0.70 ng/mL on 2025-05-15). He planned to receive immunochemotherapy with Avastin + modified FLOT on 2025-05-16. There are signs of general skin itching and lower extremity edema (2+). He is being treated with empirical ceftriaxone and symptomatic management.
Problem 1. End-stage renal disease with obstructive uropathy and AKI episodes
Problem 2. Urinary tract infection with pyuria and bacteriuria
Problem 3. Anemia and inflammation
Problem 4. Advanced malignancies: Prostate and rectal cancer with metastases
Problem 5. Skin pruritus and peripheral edema
[Treatment Assessment] (not posted)
Here is a comprehensive and integrative assessment of the immunochemotherapy regimen administered on 2025-05-16, including commentary based on NCCN Guidelines (Rectal and Prostate Cancer, 2025) and clinical pharmacology principles:
Treatment Administered (2025-05-16):
Premedications:
Notable:
A. Integrated Commentary
This regimen combines anti-angiogenic therapy (bevacizumab) with a modified FOLFOX (fluorouracil + oxaliplatin) backbone and adds docetaxel, typically seen in triplet regimens like FLOT or DCF for GI cancers. The addition of glutathione, though non-standard, may reflect an attempt to mitigate oxaliplatin-induced neurotoxicity. However, evidence of glutathione’s clinical benefit remains inconclusive.
Given the combination and dosing intensity, this resembles a “modified triple-drug induction strategy”, potentially for a gastrointestinal malignancy such as advanced/metastatic rectal or gastric cancer with curative or conversion intent.
B. Evaluation Against Guidelines
Guideline alignment: While not a guideline-standard combination, this regimen reflects a real-world, patient-adapted protocol possibly used in a high-risk GI cancer scenario (e.g., unresectable rectal cancer, peritoneal mets, etc.).
Appropriate antiemetic and premedication strategy.
C. Recommendations/Suggestions
D. Overall Assessment
This combination reflects an aggressive but tailored regimen, probably designed with conversion to surgery or response maximization in mind. However, its deviation from NCCN-recognized regimens — particularly missing leucovorin and unvalidated use of glutathione — warrants close monitoring and potentially further refinement toward more evidence-based frameworks.
[lab data]
2024-02-07 Cryoglobulin Positive
2023-10-23 Cryoglobulin Positive
2023-06-02 HBsAg (NM) Negative
2023-06-02 HBsAg Value (NM) 0.438
2023-06-02 Anti-HCV (NM) Negative
2023-06-02 Anti-HCV Value (NM) 0.040
2023-06-02 Anti-HBc (NM) Positive
2023-06-02 Anti-HBc Value (NM) 0.009
2023-06-02 Anti-HBs (NM) Positive
2023-06-02 Anti-HBs value (NM) 18.200 mIU/mL
2022-02-04 Anti-HBc Reactive
2022-02-04 Anti-HBc-Value 7.63 S/CO
2022-02-04 Anti-HBs 31.17 mIU/mL
2022-02-04 HBsAg Nonreactive
2022-02-04 HBsAg Value 0.00 IU/mL
2022-02-04 Anti-HCV Nonreactive
2022-02-04 Anti-HCV Value 0.07 S/CO
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
This is a 55-year-old woman with recurrent HPV-associated vaginal adenocarcinoma (FIGO stage I, pT1aNx) involving the vaginal stump and urinary bladder wall, previously treated with surgery, radiotherapy, and currently on Avastin (bevacizumab) plus paclitaxel/carboplatin chemotherapy (16 cycles to date, 2025-06-04 being the latest). She has multiple chronic comorbidities including type 2 diabetes mellitus, resolved hepatitis B, hypomagnesemia, and hyperlipidemia. She remains ECOG 1 with stable weight and vitals.
Disease status is clinically stable with no major new complications, but persistent urinary tract infection and chemotherapy-induced cytopenia warrant close monitoring.
Problem 1. Recurrent HPV-associated vaginal adenocarcinoma (FIGO stage I, pT1aNx)
Problem 2. Chronic urinary tract infection (likely complicated UTI) (not posted)
Problem 3. Chemotherapy-related cytopenia
Problem 4. Type 2 diabetes mellitus
Problem 5. Chronic hepatitis B (resolved) and liver monitoring
Problem 6. Hypomagnesemia
Patient Evaluation:
Problem 1. Recurrent Neutropenia (Managed with G-CSF)
Problem 2. Mild Anemia (Stable Trend) (not posted)
Problem 3. Cryoglobulinemia (Now Resolved)
Problem 4. Mild Electrolyte Fluctuations (not posted)
Final Summary (not posted)
[Granocyte and blood glucose monitoring recommendations]
Granocyte (lenograstim) is scheduled for 3 consecutive days to treat the patient’s neutropenia (WBC 2.33 x10^3/uL on 2024-07-31).
Serum glucose levels were recorded at 236 mg/dL on the morning of 2024-04-11 on the TPR panel. However, there are no recent HbA1c or serum glucose (AC) data available in the HIS5 lab panel. It is recommended that these tests be conducted routinely for better blood glucose monitoring and control.
[considering hypoglycemic adjustment for elevated glucose; normal liver enzymes and potential cessation of baogan]
A CT scan conducted on 2024-04-08 revealed a suspected cystic tumor at the vaginal stump and hepatic tumors appeared unchanged. Subsequent lab tests on 2024-04-10 showed no significant abnormalities.
However, serum glucose levels, recorded at 293 mg/dL on the morning of 2024-04-11, were elevated despite current treatment with Forxiga (dapagliflozin) and Kludone (gliclazide). Should these high glucose levels persist, there may be a need to consider additional hypoglycemic agents to manage the patient’s condition.
Given the AST and ALT levels have remained within the normal range for several weeks, discontinuation of BaoGan (silymarin) might be considered.
[reconciliation]
A refill for a 28-day quantity of Omeprotect (omeprazole) and Dulcolax (bisacodyl) was recently completed on 2023-08-05, but these medications are currently not listed in the active medication records. Kindly assess whether these drugs are no longer required for the patient.
[reconciliation]
On 2023-07-08, the patient just refilled a 28-day supply of Omeprotect (omeprazole) and Dulcolax (bisacodyl), and on 2023-07-10 refilled a 30-day supply of Anxoken (metformin), Kludone (gliclazide), and Forxiga (dapagliflozin). However, metformin is currently absent from the active medication list, and a serum glucose level of 341mg/dL was recorded on 2023-07-19 at 16:16. It is advisable to determine if the omission of metformin is deliberate or due to the scheduling of a CT scan.
[exam finding]
[MedRec]
[consultation]
This is a 64-year-old male with newly diagnosed right middle lobe adenocarcinoma of the lung, cT4N3M1c2 stage IVB (PET 2025-06-16), complicated by malignant right pleural effusion, right pneumothorax s/p pigtail, and extensive metastases (pleura, contralateral lung, liver, adrenal glands, bone, lymph nodes). The tumor is PD-L1 negative, with no actionable EGFR, ALK, or ROS1 mutations. He has comorbid COPD, type 2 diabetes mellitus (with fluctuating hyperglycemia), hypertension, hyperlipidemia, and a history of ICH in 2020. Performance status remains relatively preserved with stable vitals and no desaturation. Current management is supportive and diagnostic; systemic treatment plan not yet finalized.
Problem 1. Advanced lung adenocarcinoma with widespread metastases (cT4N3M1c2)
Problem 2. Type 2 diabetes mellitus with fluctuating hyperglycemia
Problem 3. Respiratory compromise with right pleural effusion and pneumothorax
Problem 4. Hepatitis B serostatus and reactivation risk
Problem 5. Hyponatremia (mild, new onset) (not posted)
[lab data]
2025-06-14 HBsAg Nonreactive
2025-06-14 HBsAg Value 0.28 S/CO
2025-06-14 Anti-HBc Reactive
2025-06-14 Anti-HBc Value 5.21 S/CO
2025-06-14 Anti-HCV Nonreactive
2025-06-14 Anti-HCV Value 0.16 S/CO
[exam finding]
[surgical operation]
The patient, a 72-year-old male with newly diagnosed metastatic poorly differentiated carcinoma (TTF-1 positive) of right neck lymph node origin (likely lung primary), presented with progressive neurological deterioration marked by multiple embolic infarcts and large bilateral PCA territory hemorrhagic transformation (MRA 2025-06-15). Over the recent days, consciousness has further declined (GCS 2025-06-30: E3V3M4), with stable vital signs but worsening intracranial hemorrhage (CT 2025-06-29). Concomitantly, the patient demonstrates DIC features with persistently elevated D-dimer (>10000 ng/mL FEU 2025-06-27), hypofibrinogenemia (99.6 mg/dL 2025-06-27), and thrombocytopenia (PLT 69 x10^3/uL 2025-06-29). Electrolytes show mild hypokalemia and hypernatremia, while renal function remains stable. Blood glucose fluctuates (peak 233 mg/dL 2025-06-28) under ongoing insulin therapy.
Problem 1. Neurological deterioration with PCA infarction and hemorrhage
Problem 2. Disseminated intravascular coagulation (DIC)
Problem 3. Hyperglycemia in context of steroid therapy and stress
[exam finding]
[surgical operation]
[radiotherapy]
[chemotherapy]
2025-05-29 - liposome doxorubicin 30mg/m2 45mg D5W 250mL 1hr + carboplatin AUC 4 385mg NS 250mL 2hr
2025-04-30 - liposome doxorubicin 30mg/m2 50mg D5W 250mL 1hr + carboplatin AUC 4 420mg NS 250mL 2hr
2025-04-07 - liposome doxorubicin 30mg/m2 50mg D5W 250mL 1hr + carboplatin AUC 4 440mg NS 250mL 2hr
2025-03-14 - liposome doxorubicin 30mg/m2 50mg D5W 250mL 1hr + carboplatin AUC 4 380mg NS 250mL 2hr
2025-02-13 - liposome doxorubicin 30mg/m2 50mg D5W 250mL 1hr + carboplatin AUC 5 540mg NS 250mL 2hr
2025-01-14 - liposome doxorubicin 30mg/m2 50mg D5W 250mL 1hr + carboplatin AUC 5 550mg NS 250mL 2hr
2024-06-21 - bevacizumab 7.5mg/m2 500mg NS 250mL 2hr
2024-05-30 - bevacizumab 7.5mg/m2 500mg NS 250mL 2hr
2024-04-29 - bevacizumab 7.5mg/m2 500mg NS 250mL 2hr
2024-04-09 - bevacizumab 7.5mg/m2 500mg NS 250mL 2hr
2024-03-13 - bevacizumab 7.5mg/m2 500mg NS 250mL 2hr
2024-02-19 - bevacizumab 7.5mg/m2 500mg NS 250mL 2hr
2024-01-30 - bevacizumab 7.5mg/m2 500mg NS 250mL 2hr
2024-01-03 - bevacizumab 7.5mg/m2 500mg NS 250mL 2hr
2023-12-14 - bevacizumab 7.5mg/m2 500mg NS 250mL 2hr
2023-11-13 - bevacizumab 7.5mg/m2 500mg NS 250mL 2hr
2023-10-20 - bevacizumab 7.5mg/m2 500mg NS 250mL 2hr
2023-09-28 - bevacizumab 7.5mg/m2 500mg NS 250mL 2hr
2023-09-04 - bevacizumab 7.5mg/m2 500mg NS 250mL 2hr
2023-07-24 - bevacizumab 7.5mg/m2 400mg NS 250mL 2hr
2023-07-04 - bevacizumab 7.5mg/m2 400mg NS 250mL 2hr + paclitaxel 175mg/m2 290mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + [docetaxel 30mg/m2 50mg + cisplatin 30mg/m2 50mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
2023-06-13 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 510mg NS 250mL 2hr + [docetaxel 30mg/m2 50mg + cisplatin 30mg/m2 50mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 1000mL] IP 1hr
2023-05-16 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + [docetaxel 30mg/m2 50mg + cisplatin 30mg/m2 50mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 1000mL] IP 1hr
2023-04-25 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + [docetaxel 30mg/m2 50mg + cisplatin 30mg/m2 50mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 1000mL] IP 1hr
2023-03-21 - liposome doxorubicin 35mg/m2 60mg D5W 250mL IP 90min + carboplatin AUC 5 600mg NS 250mL IP 90min (for HIPEC in operation)
2023-02-23 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + bevacizumab 15mg/kg 1000mg NS 250mL 2hr
2023-01-31 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + bevacizumab 15mg/kg 1000mg NS 250mL 2hr
2023-01-09 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + bevacizumab 15mg/kg 1100mg NS 250mL 2hr
2025-04-29 ~ - Lynparza (olaparib 150mg) HS (IPD)
2025-04-07 ~ - Lynparza (olaparib 150mg) HS (IPD)
2025-02-13 ~ - Lynparza (olaparib 150mg) BIDCC (IPD)
2025-04-16 - Xgeva (denosumab 120mg) SC (OPD)
2025-03-14 - Xgeva (denosumab 120mg) SC (IPD)
2025-02-13 - Xgeva (denosumab 120mg) SC (IPD)
2025-01-07 - Xgeva (denosumab 120mg) SC (OPD)
2025-04-07 - PG2 Lyo Injection (polysaccharides of Astragalus membranaceus 500mg) IVD (IPD)
2025-03-15 - PG2 Lyo Injection (polysaccharides of Astragalus membranaceus 500mg) IVD (IPD)
2023-01-06 ~ undergoing (as of 2025-04-30) - Vemlidy (tenofovir alafenamide 25mg) 1# QD (OPD)
The patient is a 59-year-old female with bilateral ovarian endometrioid carcinoma, now stage IV with documented metastases (liver, lung, bone). She continues on liposomal doxorubicin/carboplatin (Q3W) chemotherapy with evidence of persistent anemia (Hb 7.8 g/dL on 2025-06-30), thrombocytopenia, and hypomagnesemia despite supportive correction (MgSO4, MgO) (labs 2025-06-30). Urinary symptoms with elevated CRP (13.6 mg/dL on 2025-06-27) and positive urinalysis suggest ongoing urinary tract infection. Electrolyte disturbances (hypocalcemia, hypokalemia, hypomagnesemia) remain concerns.
Problem 1. Hematologic abnormalities (anemia, thrombocytopenia)
Problem 2. Urinary tract infection
Problem 3. Electrolyte imbalance (hypocalcemia, hypokalemia, hypomagnesemia)
Problem 4. Advanced ovarian cancer with metastatic disease
The patient is a 65-year-old woman with bilateral grade 3 ovarian
endometrioid carcinoma, initially staged as FIGO IIIC (ypT3cN1b)
following HIPEC and debulking on 2023-03-22, with subsequent progression
to stage IV due to confirmed liver, lung, bone, adrenal, and lymph node
metastases (PET 2024-12-24, MRI 2025-01-15). She received multiple lines
of chemotherapy (Taxol/Carboplatin → Bevacizumab → Lipodox/Carboplatin),
and is currently under maintenance therapy with Lynparza (olaparib) and
supportive bone metastasis management with Xgeva (denosumab).
CA-125 shows persistent biochemical control, while CA-199 demonstrates a
non-linear but generally declining trend. Latest ECOG PS is 1,
indicating preserved function. However, the patient is developing
chemotherapy-induced hematologic toxicity (anemia and thrombocytopenia),
and hypomagnesemia persists. There is no clinical evidence of active
infection, organ failure, or neurologic deterioration.
Problem 1. Metastatic ovarian endometrioid carcinoma (stage IV)
Problem 2. Chemotherapy-induced anemia and thrombocytopenia
Problem 3. Hypomagnesemia
Problem 4. Chronic viral hepatitis B (resolved/controlled carrier)
Problem 5. Cancer-related fatigue and insomnia
[assessment]
[lab data]
2024-10-01 Anti-HBc Reactive
2024-10-01 Anti-HBc-Value 5.39 S/CO
2024-09-30 Anti-HCV Nonreactive
2024-09-30 Anti-HCV Value 0.13 S/CO
2024-09-30 Anti-HBe Nonreactive
2024-09-30 Anti-HBe Ratio 1.08 S/CO
2024-09-30 HBsAg Nonreactive
2024-09-30 HBsAg Value 0.38 S/CO
[exam finding]
[MedRec] (not completed)
2025-05-01 ~ 2025-06-15 POMR Hemato-Oncology Xia HeXiong
2025-04-15 ~ 2025-04-22 POMR Hemato-Oncology Xia HeXiong
2025-02-17 ~ 2025-04-04 POMR Hemato-Oncology Xia HeXiong
2025-01-13 ~ 2025-02-02 POMR Hemato-Oncology Xia HeXiong
[surgical operation]
[consultation]
[MedRec]
[consultation]
2025-05-22 Infectious Disease
2025-05-21 Dermatology
2025-04-18 Metabolism and Endocrinology
2025-04-15 Infectious Disease
2025-04-01 Infectious Disease
2025-03-26 Dermatology
2025-02-24 Ophthalmology
2025-02-19 Diagnostic Radiology
2025-02-18 Dermatology
2025-02-18 Infectious Disease
2024-12-17 Gastroenterology
2024-11-07 Urology
2024-09-30 Radiation Oncology
2024-09-30 Gastroenterology
[radiotherapy]
[chemotherapy]
The patient, with stage IVB esophageal squamous cell carcinoma, remains under palliative chemotherapy with stable vital signs, no active fever, and stable BP control. Current medications include antihypertensives, antivirals, pain management, and supportive therapy. There is no active thrombopoietic agent such as “Revolade (eltrombopag)” prescribed presently.
Problem 1. Organ Functions and General Condition
Problem 2. Hematological Status
Problem 3. Electrolyte Management
Problem 4. Pain and Neuropathy Management
Problem 5. Antiviral and Metabolic Support
[older, not posted]
Problem 1. Organ Functions and General Condition
Problem 2. Hematological Status
Problem 3. Electrolyte and Metabolic Monitoring
Objective
Assessment
Recommendation
Problem 4. Pain and Neuropathy Management
Objective
Assessment
Recommendation
Problem 5. Antiviral Prophylaxis and HBV Status
Objective
Assessment
Recommendation
[Concor (bisoprolol) tube feeding]
Concor (bisoprolol) 5 mg immediate-release (IR) tablets are generally considered suitable for administration via a feeding tube using the simple suspension method. This method facilitates medication delivery for patients who are unable to swallow whole tablets.
Preparation using Simple Suspension Method (SSM):
Tube Administration Procedure:
[Summary]
The patient, a 62-year-old man with a history of esophageal squamous cell carcinoma (T3N3M1b, stage IVB) with metastases to the liver, spleen, and left supraclavicular lymph nodes, has been undergoing systemic chemotherapy with TPFL (docetaxel, cisplatin, fluorouracil, leucovorin) plus nivolumab since 2025-01-02. He recently completed C3 of TPFL on 2025-01-30 and underwent radiofrequency ablation (RFA) for liver metastases on 2025-01-24.
His course has been complicated by bacteremia (Escherichia coli, blood culture 2025-01-11), anemia, leukocytopenia, and thrombocytopenia, requiring supportive treatments including G-CSF (granulocyte colony-stimulating factor), eltrombopag, and transfusions. A recent CXR (2025-02-17) shows borderline cardiomegaly, prior sternotomy, and residual aortic dissection, while liver imaging confirms multiple hepatic metastases despite prior MWA (microwave ablation) and RFA.
Recent laboratory results indicate: - Persistent anemia (Hgb 9.2 g/dL, 2025-02-17) - Mild leukocytosis (WBC 7.47 ×10³/uL, 2025-02-17) but neutrophilia (93.3%) - Stable renal and hepatic function, but hypoalbuminemia (3.6 g/dL, 2025-02-17) - Iron deficiency (Fe 36 ug/dL, TIBC 313 ug/dL, 2025-02-17) - Mild hypokalemia (K 3.2 mmol/L, 2025-02-11)
His vital signs have shown episodic fever (max 38.9°C, 2025-02-17 12:44), tachycardia (HR 128 bpm, 2025-02-17 10:58), and fluctuating blood pressure (max 196/87 mmHg, 2025-02-17 10:47). These require close monitoring, especially given his history of aortic dissection.
[Problems]
Problem 1. Persistent Anemia (Multifactorial: Chemotherapy-Induced, Iron Deficiency, Chronic Disease)
Problem 2. Persistent Liver Metastases (Despite RFA & MWA, Ongoing Systemic Therapy)
Problem 3. Persistent Neutrophilia with Recent Bacteremia (Escherichia coli, 2025-01-11, ? Ongoing Infection/Inflammation)
Problem 4. Hypoalbuminemia (3.6 g/dL, 2025-02-17) with Cachexia
[Concor 5 mg Administration via Simple Suspension Method (SSM) for Tube Feeding]
For patients receiving enteral nutrition through a feeding tube, Concor 5 mg tablets can be conveniently administered using the Simple Suspension Method (SSM). This method involves crushing the tablet and dissolving it in warm water. After allowing the mixture to soak briefly, the suspension is ready for direct administration through the feeding tube.
Benefits of SSM:
[Assessment of Bowel Movements and White Blood Cell (WBC) Count]
Bowel Movement Patterns:
White Blood Cell (WBC) and Neutrophil Count (2024-11-05):
Recommendations
By addressing constipation proactively and monitoring neutrophil trends, these recommendations aim to mitigate common chemotherapy side effects and reduce infection risk during treatment.
[Clinical Course and Management of Advanced Esophageal Cancer]
Diagnosis and Presentation (2024-09-29)
Further Imaging and Findings (2024-10-07 to 2024-10-08)
Current Treatment: Chemoradiotherapy (2024-10-09 and 2024-11-05)
Progression and Labs
Consideration of Targeted Therapy
Supportive and Symptom Management
Ongoing Monitoring of Metastatic Sites
Comorbidity Management
The patient’s treatment plan aligns with aggressive systemic and local disease management strategies. A review of the patient’s medication history within HIS5 and PharmaCloud databases revealed no discrepancies.
[Concor 5mg Administration via Simple Suspension Method (SSM) - tube feeding]
For patients receiving enteral nutrition by use of a tube, Concor 5mg tablets can be easily administered using the SSM. This involves crushing the tablet and dissolving it in warm water. After a brief soaking period, the suspension can be directly administered through a feeding tube.
SSM offers several advantages:
[anti-HBc reactive: initiating prophylaxis with entecavir or tenofovir before immunosuppressive therapy]
Since the patient’s Anti-HBc is reactive, it is recommended to start Baraclude (entecavir) or Vemlidy (tenofovir alafenamide) prior to any immunosuppressive treatments (such as chemotherapy) as a prophylactic measure to prevent HBV reactivation.
[lab data]
2025-02-05 Anti-HBc Reactive
2025-02-05 Anti-HBc Value 6.48 S/CO
2025-02-04 Anti-HBc IgM Nonreactive
2025-02-04 Anti-HBc IgM Value 0.08 S/CO
2025-02-03 Anti-HCV Nonreactive
2025-02-03 Anti-HCV Value 0.07 S/CO
2025-02-03 HBsAg Nonreactive
2025-02-03 HBsAg Value 0.38 S/CO
2025-02-03 Anti-HBs 22.60 mIU/mL
2025-02-03 HIV Ab EIA Nonreactive
2025-02-03 Anti-HIV Value 0.05 S/CO
[exam finding]
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
The patient is a 69-year-old female with advanced small cell lung cancer (RUL), stage IVB (cT4N3M1c2), with known liver and bone metastases, now complicated by worsening right pleural effusion and progressive general weakness. Current labs reveal worsening liver dysfunction (elevated AST/ALT and bilirubin on 2025-06-30), persistent anemia (HGB 9.1 g/dL on 2025-06-30), thrombocytopenia (PLT 143 x10^3/uL on 2025-06-30), and electrolyte disturbances (hypokalemia). Her respiratory function is compromised with documented hypoxia (SpO2 92% on 2025-06-30). She also exhibits signs of hepatic injury progression compared to prior data.
Problem 1. Hepatic dysfunction and liver metastasis progression
Problem 2. Anemia and thrombocytopenia
Problem 3. Electrolyte disturbances and renal function
Problem 4. Respiratory compromise with right pleural effusion
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
The patient is a chronic hemodialysis-dependent individual with metastatic colorectal cancer (liver metastases, recurrent progression), receiving modified FOLFIRI chemotherapy. As of 2025-06-27, the patient remains functionally stable under integrated care, including nephrology and palliative co-management. The key concerns include:
Problem 1. Hypertension and Cardiovascular Stress under Hemodialysis
Problem 2. Anemia under ESA + Hemodialysis
Problem 3. Chemotherapy Tolerability and Mucositis
Problem 4. Immunosuppression in ESRD with Prior Autoimmune History (not posted)
Problem 5. Palliative Integration and Advance Care Planning (not posted)
This 66-year-old woman with a history of systemic lupus erythematosus (SLE), end-stage renal disease (ESRD) on hemodialysis QW135, heart failure with atrial fibrillation, and chronic hepatitis B is undergoing palliative FOLFIRI chemotherapy for sigmoid colon adenocarcinoma (pT1N0M0, G2, Stage I) with liver metastases (Stage IVa). Since chemotherapy initiation on 2024-07-17, she has remained free from acute gastrointestinal toxicities or febrile neutropenia. However, she has developed progressive anemia and thrombocytopenia, worsening renal function, and new cardiovascular findings.
On 2025-04-01, she received epoetin beta following a hemoglobin level of 7.1 g/dL, in line with nephrology recommendations for ESA initiation when Hgb <11 g/dL. Echocardiography on 2025-03-06 confirmed moderate aortic stenosis and mild pulmonary hypertension. Although autoimmune hemolysis is not definitively diagnosed, the presence of a positive direct Coombs test (2025-03-11), systemic lupus erythematosus history, and persistent normocytic anemia despite transfusions raise clinical suspicion.
Problem 1. ESRD on Hemodialysis
Problem 2. Progressive Anemia and Suspected Autoimmune Hemolysis
Problem 3. Neutropenia and Chemotherapy-Related Marrow Suppression
Problem 4. Colon Cancer with Liver Metastasis under Palliative FOLFIRI
Problem 5. SLE with Multisystem Involvement (LN, AIHA)
Problem 6. Cardiovascular Disease: HFpEF, Aortic Stenosis, AFib
Problem 7. Thyroid Dysfunction - Suspected Subclinical Hypothyroidism
Since the last review on 2025-01-17, notable changes in the patient’s condition include:
Problem 1: Anemia (Worsening)
Problem 2: Renal Function (Improved with Dialysis)
Problem 3: Hypertension and Bradycardia
Problem 4: Liver Metastases (Stable on FOLFIRI)
Problem 5: Chronic Hepatitis B (Stable on Vemlidy)
[Summary]
The patient is a 66-year-old woman with a history of adenocarcinoma of the sigmoid colon (stage IVa due to liver metastases) who has been receiving palliative chemotherapy with FOLFIRI since 2024-07-17.
She also has end-stage renal disease (ESRD) under hemodialysis three times weekly (QW135), heart failure, atrial fibrillation, systemic lupus erythematosus (SLE), and chronic hepatitis B.
Her condition is currently stable, with planned chemotherapy (C5D1) starting on 2025-01-17.
Notable ongoing issues include anemia, hypertension, and renal dysfunction.
Vital signs are stable, with mild hypertension (highest 178/78 mmHg on 2025-01-15).
[Problems]
Problem 1. Anemia
Problem 2. End-Stage Renal Disease (ESRD)
Problem 3. Hypertension
Problem 4. Liver Metastases (Adenocarcinoma of S-Colon)
Problem 5. Chronic Hepatitis B
[persistent anemia in ESRD patient post-neutropenia recovery]
Granocyte (lenograstim) has been prescribed, and the updated lab results show no more neutropenia.
However, anemia persists, likely due to the patient’s end-stage renal disease (ESRD). The records indicate a blood transfusion on 2024-10-02. If the anemia is indeed caused by renal insufficiency, the use of erythropoiesis-stimulating agents (ESAs) could be considered as a treatment option.
2024-10-03 WBC 8.04 x10^3/uL
2024-10-01 WBC 1.92 x10^3/uL
2024-09-24 WBC 3.21 x10^3/uL
2024-10-03 Neutrophil 82.5 %
2024-10-01 Neutrophil 69.8 %
2024-09-24 Neutrophil 75.7 %
2024-10-03 HGB 8.7 g/dL
2024-10-01 HGB 7.6 g/dL
2024-09-24 HGB 9.1 g/dL
[Considerations for Irinotecan Dosing and Timing with Hemodialysis]
Irinotecan, a prodrug, is hydrolyzed into the active metabolite SN-38, which is further metabolized into the inactive glucuronide conjugate SN-38G. While the primary elimination route is biliary, approximately 32% of the dose is excreted via urine (~22% as unchanged drug, ~3% as SN-38G, and <1% as SN-38). SN-38 is highly protein-bound (~99%), primarily to albumin. Ref: https://doi.org/10.1200/JCO.2022.40.16_suppl.e1351
Considering that liver function results on 2024-08-25 were normal and the patient is currently undergoing hemodialysis, administering irinotecan 1 hour before dialysis might result in the drug being partially dialyzed before it fully converts to SN-38, potentially reducing the actual effective dose of SN-38. Currently, the FOLFIRI regimen has already reduced irinotecan from 180 mg/m² to 120 mg/m². Please consider the possibility of unintentional underdosing of irinotecan.
[managing FOLFIRI regimen in HD patients]
Systemic treatment has not yet been initiated, and tumor markers continue to show a rising trend.
The planned FOLFIRI regimen includes fluorouracil, which is used for the patient on intermittent hemodialysis (thrice weekly). Fluorouracil itself is not significantly dialyzable; however, its metabolite FBAL may be substantially removed by dialysis (extraction ratio 0.73 to 0.84). No dosage adjustment is necessary for fluorouracil. When the scheduled dose falls on a hemodialysis day, it should be administered after hemodialysis. Patients must be monitored closely for the potential development of hyperammonemic encephalopathy associated with FBAL accumulation in those with end-stage kidney disease. Removing FBAL by hemodialysis can be effective in preventing or treating hyperammonemia.
However, the use of irinotecan in the patient on intermittent hemodialysis poses risks. Irinotecan may be partially dialyzable, but its active metabolite, SN38, is not. The manufacturer does not recommend its use due to the higher risk of toxicity in patients with end-stage kidney disease (ESKD). Initially, if benefits outweigh the risks, it may be started at 50% to 66% of the usual recommended dose. Given the variability in patient responses, when the usual indication-specific dose is 100 to 150 mg/m2 once weekly, it may be safest to start at 50 mg/m2 once weekly. Doses may be cautiously increased if tolerated; however, severe toxicity at 80 mg/m2 weekly (grade 4 neutropenia and death in a patient with UGT1A polymorphism) and 100 mg/m2 weekly (grade 4 diarrhea) has been reported. Irinotecan should be administered after hemodialysis or on non-dialysis days.
Currently, the patient’s multiple liver metastases have not affected AST, ALT, or bilirubin readings, and there is no need to adjust the FOLFIRI dosage for liver function at this time.
[lab data]
2024-05-24 HBV-DNA-PCR Target Not Detected IU/mL
2023-09-13 HBV-DNA-PCR Target Not Detected IU/mL
2023-09-11 HBsAg Nonreactive
2023-09-11 HBsAg Value 0.49 S/CO
2023-09-11 Anti-HCV Nonreactive
2023-09-11 Anti-HCV Value 0.12 S/CO
2023-09-11 Anti-HBc Reactive
2023-09-11 Anti-HBc Value 5.99 S/CO
2020-10-31 HIV Ab-EIA Nonreactive
2020-10-31 Anti-HIV Value 0.06 S/CO
2020-10-31 Anti-HCV Nonreactive
2020-10-31 Anti-HCV Value 0.13 S/CO
2020-10-31 Anti-HAV IgG Reactive
2020-10-31 Anti-HAV IgG Value 10.02 S/CO
2020-10-31 HBsAg Nonreactive
2020-10-31 HBsAg Value 0.36 S/CO
2020-10-31 Anti-HAV IgM Nonreactive
2020-10-31 Anti-HAV IgM Value 0.47 S/CO
[exam findings]
2025-05-30 CT - abdomen
2025-04-29 Pathology - stomach biopsy
2025-04-29 Esophagogastroduodenoscopy, EGD
2025-04-24 Nasopharyngoscopy
2025-04-02 Nasopharyngoscopy
2025-03-03 CT - abdomen
2025-02-10 Sonography - abdomen
2025-02-03 PTCD (percutaneous transhepatic cholangial drainage) revision
2025-01-02 2D transthoracic echocardiography
2024-12-10 CXR
2024-12-06 Body fluid cytology - ascites
2024-12-03 CT - abdomen
2024-12-02 Abdomen - Standing (Diaphragm)
2024-12-02 Paracentesis
2024-11-28 CXR
2024-11-27 PTCD (percutaneous transhepatic cholangial drainage) revision
2024-11-08 CT - abdomen
2024-11-07 CXR
2024-11-07, -11-03 Abdomen - Standing (Diaphragm)
2024-08-28 CT - abdomen
2024-07-30 CXR
2024-05-24 PTCD (percutaneous transhepatic cholangial drainage)
2024-05-18 CT - abdomen
2024-04-02 Nerve Conduction Velocity, NCV
2024-04-02 Nerve Conduction Velocity, NCV
2024-02-19 Tc-99m MDP bone scan with SPECT
2024-02-17 CT - abdomen
2024-01-24 Patho - stomach biopsy
2024-01-24 EGD
2024-01-23 MRI - brain
2023-12-14 ENT Hearing Test
2023-11-14 CT - abdomen
2023-08-29 Patho - liver partial resection
2023-08-14 PET
2023-07-19 CT - abdomen
2023-07-04 SONO - abdomen for follow-up
2023-03-30 Patho - liver partial resection
2023-03-17 CT - abdomen
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
2025-06-26 - pembrolizumab 200mg NS 100mL 1hr + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (80%)
2025-06-02 - pembrolizumab 200mg NS 100mL 1hr (Keytruda)
2025-05-29 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 620mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (80%)
2025-05-13 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 2800mg/m2 3530mg NS 500mL 46hr (80%)
2025-04-24 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (80%)
2025-04-07 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (80%)
2025-03-31 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (80%)
2025-02-27 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (80%)
2025-02-07 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (80%)
2025-01-17 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr (80%)
2024-12-31 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr
2024-12-03 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr
2024-11-04 - nivolumab 240mg NS 100mL 1hr + carboplatin AUC 2 250mg NS 250mL 2hr D1 + topotecan 1.5mg/m2 2mg D5W 60mL 30min D1-4
2024-10-09 - nivolumab 240mg NS 100mL 1hr + carboplatin AUC 2 250mg NS 250mL 2hr D1 + topotecan 1.5mg/m2 2mg D5W 60mL 30min D1-4
2024-09-16 - nivolumab 240mg NS 100mL 1hr + carboplatin AUC 2 250mg NS 250mL 2hr D1 + topotecan 1.5mg/m2 2mg D5W 60mL 30min D1-4
2024-08-26 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 590mg NS 250mL 2hr + fluorouracil 2800mg/m2 4100mg NS 500mL 46hr (FOLFOX 90%)
2024-08-09 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 590mg NS 250mL 2hr + fluorouracil 2800mg/m2 4100mg NS 500mL 46hr (FOLFOX 90%)
2024-07-23 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 590mg NS 250mL 2hr + fluorouracil 2800mg/m2 4100mg NS 500mL 46hr (FOLFOX 90% due to WBC 2890, ANC 1757)
2024-07-03 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX)
2024-06-18 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX)
2024-05-28 - leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr
2024-05-27 - topotecan 1.5mg/m2 2.5mg D5W 80mL 30min D1-4 + carboplatin AUC 2 250mg NS 250mL 2hr D1
2024-02-16 - furosemide 10mg NS 1000mL 4hr D1 (before CDDP) + cisplatin 70mg/m2 120mg NS 500mL 3hr D1 + furosemide 10mg NS 1000mL 4hr D1 (after CDDP) + etoposide 90mg/m2 155mg NS 500mL 2hr D1-3
2024-01-24 - furosemide 10mg NS 1000mL 4hr D1 (before CDDP) + cisplatin 70mg/m2 110mg NS 500mL 3hr D1 + furosemide 10mg NS 1000mL 4hr D1 (after CDDP) + etoposide 90mg/m2 150mg NS 500mL 2hr D1-3
2024-01-02 - furosemide 10mg NS 1000mL 4hr D1 (before CDDP) + cisplatin 70mg/m2 110mg NS 500mL 3hr D1 + furosemide 10mg NS 1000mL 4hr D1 (after CDDP) + etoposide 90mg/m2 150mg NS 500mL 2hr D1-3
2023-12-11 - furosemide 10mg NS 1000mL 4hr D1 (before CDDP) + cisplatin 70mg/m2 110mg NS 500mL 3hr D1 + furosemide 10mg NS 1000mL 4hr D1 (after CDDP) + etoposide 90mg/m2 150mg NS 500mL 2hr D1-3
2023-11-13 - furosemide 10mg NS 1000mL 4hr D1 (before CDDP) + cisplatin 70mg/m2 110mg NS 500mL 3hr D1 + furosemide 10mg NS 1000mL 4hr D1 (after CDDP) + etoposide 90mg/m2 145mg NS 500mL 2hr D1-3
2023-10-23 - furosemide 10mg NS 1000mL 4hr D1 (before CDDP) + cisplatin 70mg/m2 110mg NS 500mL 3hr D1 + furosemide 10mg NS 1000mL 4hr D1 (after CDDP) + etoposide 90mg/m2 145mg NS 500mL 2hr D1-3
2023-10-03 - furosemide 10mg NS 1000mL 4hr D1 (before CDDP) + cisplatin 70mg/m2 120mg NS 500mL 3hr D1 + furosemide 10mg NS 1000mL 4hr D1 (after CDDP) + etoposide 90mg/m2 160mg NS 500mL 2hr D1-3
2023-09-11 - NS 1000mL 4hr (before CDDP) + furosemide 20mg (after NS) + cisplatin 70mg/m2 105mg NS 500mL 3hr D1 + NS 1000mL 4hr (after CDDP) + furosemide 20mg (after NS) + etoposide 100mg/m2 150mg NS 500mL 2hr D1-3
The patient is a 59-year-old woman with stage IV gallbladder neuroendocrine carcinoma with liver metastases (pT2aN0M1), post resection and multiple chemotherapy regimens (CDDP+VP-16 ×8, Topotecan/Carboplatin, FOLFOX, now FOLFIRI + Lenvima + Pembrolizumab). The disease status is currently stable (CT 2025-05-30). Despite multiple prior progressions, the patient remains functionally preserved (G1 fatigue) with tolerable adverse events from therapy. Current issues include worsening hyperbilirubinemia, G2 hepatic enzyme elevation, G3 thrombocytopenia, G2 peripheral neuropathy, and G1 gastrointestinal and hematologic toxicities. The patient is on cycle 6 FOLFIRI with concurrent pembrolizumab and lenvatinib.
Problem 1. Hyperbilirubinemia and Hepatic Dysfunction
Problem 2. Chemotherapy-Induced Thrombocytopenia (Grade 3)
Problem 3. Gallbladder Neuroendocrine Carcinoma with Liver Metastases (Stable Disease)
Problem 4. Electrolyte and Nutritional Imbalances (not posted)
Problem 5. Chemotherapy-Related Sensory Neuropathy (Grade 2)
This 59-year-old female with gallbladder neuroendocrine carcinoma, high grade, pT2aN0M1, stage IV post-S5/S4b resection (2023-08-28), has undergone extensive lines of chemotherapy (CDDP + VP-16 x8, FOLFOX, Topotecan/Carboplatin/Nivolumab, now FOLFIRI) and targeted therapy Lenvima (lenvatinib), with confirmed progressive liver and peritoneal metastasis. She was recently admitted (2025-05-29 to 2025-06-02) for FOLFIRI C5D15 and received pembrolizumab 200mg on 2025-06-02. On this date, lab showed Grade 3 thrombocytopenia (PLT 44 x10^3/uL), Grade 2 anemia (Hb 8.6 g/dL), and leukopenia (WBC 2.00 x10^3/uL). Transfusion of LPRBC was arranged. Vital signs were stable (BP 127/68 mmHg, Temp 36.9°C), and she remained afebrile with PS 1 (ECOG). CT on 2025-05-30 suggested stable hepatic and peritoneal disease, despite mild progression of one lesion.
Problem 1. Gallbladder neuroendocrine carcinoma with liver and peritoneal metastases, pT2aN0M1, stage IV
Problem 2. Chemotherapy-induced pancytopenia (anemia, thrombocytopenia, leukopenia)
Problem 3. Hepatic dysfunction and HBV carrier status
Problem 4. Chemotherapy-related gastrointestinal complications
[Key Findings]
Systemic Disease Progression
Primary diagnosis: Gallbladder neuroendocrine carcinoma, high-grade (initially pT2aN0, now stage IV).
Current progression:
Liver Function and Tumor Markers
Hematology and Bone Marrow Function
Anemia of chronic disease:
Thrombocytopenia resolved: PLT increased to 164 x 10^3/uL (2024-11-27) compared to critically low 45 x 10^3/uL (2024-10-16), likely reflecting marrow recovery after prior chemotherapy-induced myelosuppression.
Leukopenia stable: WBC 4.78 x 10^3/uL (2024-11-27).
CNS and Neurological Findings
Current Chemotherapy and Responses
Complications and Supportive Issues
Portal hypertension: Manifesting as splenomegaly, spontaneous shunt, and ascites.
PTCD dysfunction: Likely recurrent obstruction due to bile duct compression.
Nutritional status:
Comprehensive Status Assessment
[Current Active Medications Review]
Medications for Symptom Management
Medications for Hepatic and Biliary Support
Medications for Cardiovascular and Metabolic Conditions
Medications for Nutritional Support and Anemia
[stable WBC and improved bilirubin levels under FOLFOX]
Since the chemotherapy started in late May, WBC levels have consistently remained above 2.5K/uL, with no severe neutropenia occurring. The current FOLFOX regimen is being administered at 90% of the standard dose.
The elevated conjugated bilirubin levels have shown a downward trend, indicating improvement.
Additionally, there has been no recent elevation in CEA, and the CA199 spike observed in late July has decreased by mid-August.
Overall, the treatment appears to be effective, with no major adverse reactions and an improvement in jaundice symptoms. No medication issues have been identified.
2024-08-25 WBC 2.69 x10^3/uL
2024-08-20 WBC 3.32 x10^3/uL
2024-08-09 WBC 2.86 x10^3/uL
2024-08-07 WBC 3.95 x10^3/uL
2024-07-30 WBC 5.60 x10^3/uL
2024-07-23 WBC 2.89 x10^3/uL
2024-07-17 WBC 2.93 x10^3/uL
2024-07-03 WBC 2.98 x10^3/uL
2024-06-24 WBC 3.61 x10^3/uL
2024-06-20 WBC 6.35 x10^3/uL
2024-06-18 WBC 4.75 x10^3/uL
2024-06-16 WBC 4.62 x10^3/uL
2024-06-12 WBC 10.93 x10^3/uL
2024-06-03 WBC 2.68 x10^3/uL
2024-05-30 WBC 3.89 x10^3/uL
2024-05-27 WBC 4.73 x10^3/uL
2024-08-25 Bilirubin direct 0.32 mg/dL
2024-08-09 Bilirubin direct 0.29 mg/dL
2024-07-23 Bilirubin direct 0.43 mg/dL
2024-06-24 Bilirubin direct 0.47 mg/dL
2024-06-20 Bilirubin direct 0.65 mg/dL
2024-06-18 Bilirubin direct 0.77 mg/dL
2024-06-16 Bilirubin direct 1.66 mg/dL
2024-06-03 Bilirubin direct 1.10 mg/dL
2024-05-30 Bilirubin direct 1.40 mg/dL
2024-05-27 Bilirubin direct 1.83 mg/dL
2024-05-23 Bilirubin direct 4.71 mg/dL
2024-08-13 CA-199 (NM) 60.189 U/ml
2024-07-22 CA-199 (NM) 104.381 U/ml
2024-07-09 CA-199 (NM) 77.640 U/ml
2024-06-14 CA-199 (NM) 47.320 U/ml
[Post-PTCD Concerns: Elevated Bilirubin & Rising CA-199 Marker]
Recent PTCD and Follow-up Concerns: The patient recently underwent percutaneous transhepatic cholangiodrainage (PTCD) on 2024-05-24. However, her total bilirubin level has since risen to 2.71 mg/dL. This elevation may warrant consideration of another PTCD procedure if symptoms reappear.
2024-06-16 Bilirubin total 2.71 mg/dL
2024-06-12 Bilirubin total 1.62 mg/dL
2024-06-03 Bilirubin total 1.96 mg/dL
2024-06-16 Bilirubin direct 1.66 mg/dL
2024-06-03 Bilirubin direct 1.10 mg/dL
Rising CA-199 Marker:
Additionally, the patient’s CA-199 tumor marker level appears to be increasing.
[drug identification]
Since the drug to be identified is an unpackaged tablet, its quality and expiration date cannot be confirmed, so the response is that the drug cannot be identified.
An in-hospital porter will be sent to deliver the tablets to the ward.
[exam finding]
[MedRec]
2025-06-03 MultiTeam (not completed)
2023-09-24 ~ 2023-09-26 POMR Hemato-Oncology He JingLiang
2023-09-21 SOAP Obstetrics and Gynecology Chen GuoHu
2023-09-18 ~ 2023-09-21 POMR General and Gastrointestinal Surgery Li ChaoShu
2023-09-18 SOAP Medical Emergency He YaoCan
2023-09-14 SOAP Hemato-Oncology He JingLiang
2023-08-27 ~ 2023-09-08 POMR Obstetrics and Gynecology Chen GuoHu
2023-08-10 SOAP Obstetrics and Gynecology Chen GuoHu
2023-08-07 SOAP Obstetrics and Gynecology Chen GuoHu
2023-08-05 SOAP General and Gastrointestinal Surgery Chen YanZhi
2023-08-04 SOAP Gastroenterology Xu RongYuan
2020-10-15 ~ 2020-10-17 POMR General and Gastrointestinal Surgery Lai JieWen
2019-05-02 SOAP Obstetrics and Gynecology Hong ZhengXiu
[surgical operation]
[chemotherapy]
2025-06-25 - gemcitabline 1000mg/m2 1500mg NS 100mL 30min + [paclitaxel 30mg/m2 45mg cisplatin 30mg/m2 45mg gentamicin 40mg NaHCO3 2800mg NS 400mg] IP 1hr
2025-06-11 - gemcitabline 1000mg/m2 1500mg NS 100mL 30min
2025-05-28 - gemcitabline 1000mg/m2 1500mg NS 100mL 30min + [paclitaxel 30mg/m2 45mg cisplatin 30mg/m2 45mg gentamicin 40mg NaHCO3 2800mg NS 400mg] IP 1hr
2025-05-13 - gemcitabline 1000mg/m2 1500mg NS 100mL 30min
2025-05-02 - gemcitabline 1000mg/m2 1500mg NS 100mL 30min
2025-04-28 - [paclitaxel 30mg/m2 45mg cisplatin 30mg/m2 45mg gentamicin 40mg NaHCO3 2800mg NS 400mg] IP 1hr
2025-04-25 - gemcitabline 1000mg/m2 1500mg NS 100mL 30min
2025-03-26 - [liposome doxorubicin 30mg/m2 50mg D5W 90min + carboplatin AUC 5 550mg NS 250mL 90min] IP 90 min (HIPEC)
2025-01-23 - liposome doxorubicin 30mg/m2 40mg D5W 1hr + carboplatin AUC 5 400mg NS 250mL 2hr
2025-01-02 - bevacizumab 7.5mg/m2 400mg NS 250mL 2hr + liposome doxorubicin 30mg/m2 40mg D5W 250mL 1hr + carboplatin AUC 5 380mg NS 250mL 2hr
2024-12-10 - bevacizumab 7.5mg/m2 400mg NS 250mL 2hr + liposome doxorubicin 30mg/m2 40mg D5W 250mL 1hr + carboplatin AUC 5 380mg NS 250mL 2hr
2024-11-19 - bevacizumab 7.5mg/m2 400mg NS 250mL 2hr + liposome doxorubicin 30mg/m2 40mg D5W 250mL 1hr + carboplatin AUC 5 460mg NS 250mL 2hr
2024-10-28 - bevacizumab 7.5mg/m2 400mg NS 250mL 2hr + liposome doxorubicin 30mg/m2 40mg D5W 250mL 1hr + carboplatin AUC 5 560mg NS 250mL 2hr
2024-10-04 - bevacizumab 7.5mg/m2 400mg NS 250mL 2hr + liposome doxorubicin 30mg/m2 40mg D5W 250mL 1hr + carboplatin AUC 5 560mg NS 250mL 2hr
2024-09-09 - bevacizumab 7.5mg/m2 400mg NS 250mL 2hr + liposome doxorubicin 30mg/m2 40mg D5W 250mL 1hr + carboplatin AUC 5 590mg NS 250mL 2hr
2024-08-19 - bevacizumab 7.5mg/m2 400mg NS 250mL 2hr + liposome doxorubicin 30mg/m2 40mg D5W 250mL 1hr + carboplatin AUC 5 575mg NS 250mL 2hr
2024-06-04 - bevacizumab 7.5mg/m2 400mg NS 250mL 2hr
2024-05-15 - bevacizumab 7.5mg/m2 400mg NS 250mL 2hr
2024-04-18 - bevacizumab 7.5mg/m2 400mg NS 250mL 2hr
2024-03-27 - bevacizumab 7.5mg/m2 400mg NS 250mL 2hr
2024-03-02 - bevacizumab 7.5mg/m2 400mg NS 100mL 1.5hr + paclitaxel 175mg/m2 260mg NS 250mL 3hr + carboplatin AUC 5 520mg NS 250mL 2hr
2024-02-03 - bevacizumab 7.5mg/m2 400mg NS 100mL 1.5hr + paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 400mg NS 250mL 2hr
2024-01-13 - bevacizumab 7.5mg/m2 400mg NS 100mL 1.5hr + paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 440mg NS 250mL 2hr
2023-12-22 - bevacizumab 7.5mg/m2 400mg NS 100mL 1.5hr + paclitaxel 175mg/m2 250mL NS 250mL 3hr + carboplatin AUC 5 460mg NS 250mL 2hr (Avastin + paclitaxel + carboplatin; Q3W)
2023-11-27 - bevacizumab 7.5mg/m2 400mg NS 100mL 1.5hr + paclitaxel 175mg/m2 250mL NS 250mL 3hr + carboplatin AUC 5 460mg NS 250mL 2hr (Avastin + paclitaxel + carboplatin; Q3W)
2023-11-07 - bevacizumab 7.5mg/m2 400mg NS 100mL 1.5hr + paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 540mg NS 250mL 1hr (Avastin + paclitaxel + carboplatin; Q3W)
2023-10-16 - ……………………………………. paclitaxel 175mg/m2 245mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr (paclitaxel + carboplatin; Q3W)
2023-09-25 - ……………………………………. paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (paclitaxel + carboplatin; Q3W)
Patient Summary
Problem 1. Advanced ovarian cancer (stage IV) with recent C6 gemcitabine/IP chemotherapy
Problem 2. Grade 3 anemia (HGB 6.5–8.0 g/dL)
Problem 3. Nutritional and GI symptom burden (nausea, appetite loss)
Problem 4. Tenckhoff catheter with IP chemotherapy delivery
Problem 5. Psycho-oncological stress and coping
The patient continues to receive medications for symptom control, anemia management, and antiviral prophylaxis. Active medications include Baraclude (entecavir) for Hepatitis B prophylaxis, Foliromin (ferrous sodium citrate) for anemia, and supportive medications like Acetal (acetaminophen) for pain and Granocyte (lenograstim) for neutropenia. The updated medication list suggests the ongoing management of anemia, potential bleeding risks, and chemotherapy-induced side effects, which align with the patient’s clinical status.
Problem 1. Persistent Anemia
Problem 2. Residual and Recurrent Malignancy
Problem 3. Thrombocytopenia and Bleeding Risk
Problem 4. Electrolyte Imbalance
[Medication Review]
Problem 1: Active Disease and Chemotherapy
Problem 2: Chemotherapy-Induced Nausea and Vomiting (CINV)
Problem 3: Viral Suppression and HBV Reactivation Risk
Problem 4: Pain, Anxiety, and Sedation
Problem 5: Uric Acid Management
Review Summary:
[Anemia]
Objective:
Assessment:
Recommendations:
Primary Findings:
Ongoing ovarian cancer (high-grade serous carcinoma) with peritoneal carcinomatosis and lymph node metastases (stage IIIC).
Chemotherapy-induced bone marrow suppression:
Current Concerns:
Recommendations:
[Analysis of CA-125 Trends and Correlation with Treatment Effects]
CA-125 is a key marker used to monitor disease progression and response to treatment in ovarian cancer, particularly in this case of high-grade serous carcinoma. Below is a detailed review of the patient’s CA-125 trend, correlated with treatment interventions and imaging findings:
Correlating Treatment Phases and Imaging
Clinical Comments on Treatment Effects
Recommendations:
Lab results remained largely unremarkable on 2023-12-21. Medication reconciliation confirmed no discrepancies.
Notably, the addition of bevacizumab to the paclitaxel + carboplatin regimen since 2023-11-07 has been associated with a sustained decline in CA-125 levels. Additionally, no adverse events related to bevacizumab, such as hypertension, gastrointestinal perforation, bleeding, or thromboembolic events, have been reported to date.
Upon review of the PharmaCloud database, the patient’s medication records are consistent with no discrepancies.
Following the cytoreductive surgery performed on 2023-08-29 and 2 subsequent cycles of the paclitaxel and carboplatin regimen administered on 2023-09-25 and 2023-10-16, there was a significant reduction in the tumor marker CA-125.
Avastin (bevacizumab) has been added to the treatment protocol beginning with the 3rd cycle. The patient should be closely monitored for signs of hypertension, gastrointestinal perforation, bleeding or thromboembolic events.
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
[Ref]
Chemotherapeutic regimens used for the treatment of Hodgkin lymphoma - 2025-03-03 - https://www.uptodate.com/contents/image?imageKey=HEME%2F74186
This 38-year-old woman has classical Hodgkin lymphoma, nodular sclerosis type, involving the pericardium (diagnosed 2025-01-24) and staged as Ann Arbor stage IV due to extranodal invasion. She has been receiving BV-AVD Q2W chemotherapy with acceptable tolerance, currently at Cycle 4 Day 15 (2025-06-25). Disease shows partial metabolic response on PET (2025-04-30), with new right subphrenic uptake suggestive of possible residual/recurrent disease. She remains clinically stable with G1 side effects only, including anemia (Hb 10.5 g/dL) and fatigue. No major organ dysfunction is detected.
Problem 1. Classical Hodgkin lymphoma, stage IV (invasion of pericardium)
Problem 2. Chemotherapy-induced anemia and thrombocytopenia
Problem 3. Leukocytosis post G-CSF (below not posted)
Problem 4. Constipation and appetite loss
Problem 5. Electrolyte and organ function monitoring
[S - Subjective]
The patient, a postpartum mother, confirmed she is not currently breastfeeding, eliminating concerns about medication safety for lactation.
The patient reported skin rash with itching over four limbs. Medications have already been prescribed to manage these symptoms.
[O - Objective]
Recent Chemotherapy (2025-03-03):
Cardiac Function:
Active Medication List:
[A - Assessment]
Hodgkin Lymphoma (Stage IIB) undergoing BD-AVD chemotherapy:
Skin Rash:
Electrolyte Monitoring:
Cardiac Considerations:
GI Protection:
[P - Plan & Recommendations]
Monitor for Chemotherapy-Related Toxicities:
Continue Current Medications:
Electrolyte Management:
Cardiac Follow-Up:
Patient Education:
Summary
Summary
This 38-year-old woman has been diagnosed with classical Hodgkin lymphoma (nodular sclerosis subtype) based on histopathology from mediastinal lymph node and thymus (2025-01-24). The disease was initially detected via CT chest (2025-01-13, 2025-01-15), which revealed a mediastinal mass with extensive lymphadenopathy.
The PET (2025-02-06) showed hypermetabolic activity in mediastinal, supraclavicular, pleural, and bone marrow regions (Deauville Score 2-3). However, bone marrow biopsy (2025-02-07) was negative for malignancy, no evidence of direct bone marrow involvement for now.
Based on nodal involvement limited to above the diaphragm (mediastinal, supraclavicular, pleural), and the presence of B symptoms (e.g., fever, weight loss, or night sweats, if present), her Hodgkin lymphoma should be Stage IIB under the Lugano classification.
Problem 1. Classical Hodgkin Lymphoma (Stage IIB)
Problem 2. Pulmonary Complications (Pleural Effusion, Pneumonia, Vocal Cord Paralysis) (below not posted)
Problem 3. Hematologic Complications (Anemia, Thrombocytosis, Leukocytosis)
[exam finding]
[MedRec]
[Subjective]
Medication use inquiry
Caregiver response
[Objective]
Current cardiology prescription as of 2025-06-25 (28-day supply)
Laboratory data from 2025-06-18
Blood pressure trend
[Assessment]
Heart failure regimen adequacy
Polypharmacy and CNS medication concerns
Electrolyte monitoring
Statin double therapy
[Plan / Recommendation]
Patient/caregiver education and adherence support
Sedative use review
Electrolyte and renal function monitoring
Lipid management
The patient has heart failure with preserved renal function and recurrent hypernatremia, post-acute decompensated cardiac event (elevated hs-Troponin I up to 9049.1 pg/mL on 2025-05-26), now clinically stable on cardiology follow-up. Blood gases show trends of chronic respiratory acidosis with partial metabolic compensation. Recurrent borderline hypokalemia and persistent anemia are noted. Evidence of prior UTI with glucosuria and yeast on urinalysis (2025-05-26) likely reflects SGLT2 inhibitor effect but requires continued surveillance. The medication regimen includes appropriate heart failure and cardiovascular risk management, but the use of several agents affecting renal perfusion, blood pressure, and electrolytes necessitates close monitoring.
Problem 1. Heart failure with recent ischemic insult
Problem 2. Hypernatremia and fluid balance
Problem 3. Anemia
Problem 4. Renal function and nephrotoxic risk
Problem 5. Electrolyte imbalance (Hypokalemia, Hypocalcemia)
Problem 6. Chronic compensated respiratory acidosis
[Lipanthyl Supra (fenofibrate): an available alternative for gemfibrozil]
The gemfibrozil 600mg QD inquired about over the phone belongs to the ATC classification C10AB. A list of drugs in the same class is as follows. (https://atcddd.fhi.no/atc_ddd_index/?code=C10AB)
Our hospital has one available drug in this class, Lipanthyl Supra, where 1 tab of Lipanthyl Supra is approximately equivalent to 1g of gemfibrozil.
According to UpToDate, the significant adverse reactions of fenofibrate include hepatic effects, myopathy/rhabdomyolysis, photosensitivity, and renal effects. Although the incidence is low, these should still be monitored.
ATC code Name DDD U Adm.R Note Available - C10AB01 clofibrate 2 g
O
- C10AB02 bezafibrate 0.6 g O
- C10AB03 aluminium clofibrate
- C10AB04 gemfibrozil 1.2 g O
- C10AB05 fenofibrate 0.2 g O micronised Lipanthyl Supra FC (fenofibrate
160mg/tab) - C10AB06 simfibrate
- C10AB07 ronifibrate
- C10AB08 ciprofibrate 0.1 g O
- C10AB09 etofibrate
- C10AB10 clofibride
- C10AB11 choline fenofibrate 0.135 g O Refers to fenofibric acid -
C10AB12 pemafibrate
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
This 66-year-old woman has stage IVB right middle lobe lung adenocarcinoma (cT4N2M1c), EGFR exon 19 deletion (+), PD-L1 negative, with known brain metastases and newly suspected bone metastasis. She is currently receiving dual anti-EGFR therapy with oral “Giotrif (afatinib)” and IV “Rybrevant (amivantamab)”, combined with “Avastin (bevacizumab)” as angiogenesis inhibitor, with evidence of tumor regression on CT (2025-06-14). She has complications including idiopathic left-sided sudden hearing loss (progressive SNHL), pyogenic granulomas, internal hemorrhoids requiring ligation, and eczema/angioedema. Supportive medications include proton pump inhibitors, antihistamines, topical antibiotics, and emollients. Labs are stable with mild hyponatremia. Comorbidities include hypertension, hyperlipidemia, resolved HBV infection (on prophylactic “Vemlidy (tenofovir alafenamide)”). Overall disease is partially responsive, but symptom burden remains moderate.
Problem 1. Right middle lobe lung adenocarcinoma, cT4N2M1c stage IVB, EGFR exon 19(+), PD-L1(-)
Problem 2. Left sudden idiopathic sensorineural hearing loss (SNHL)
Problem 3. Pyogenic granuloma and dermatologic manifestations
Problem 4. Internal hemorrhoids
Problem 5. Electrolyte abnormalities
Problem 6. Resolved HBV infection with antiviral prophylaxis
[lab data]
2025-03-12 HBV DNA PCR (quan) 508 IU/mL
2025-03-11 HBeAg Nonreactive
2025-03-11 HBeAg Value 0.392 S/CO
2025-02-26 HBsAg (NM) Positive
2025-02-26 HBsAg Value (NM) 434
2025-02-26 Anti-HBc (NM) Positive
2025-02-26 Anti-HBc Value (NM) 0.009
2025-02-26 Anti-HCV (NM) Negative
2025-02-26 Anti-HCV Value (NM) 0.034
2025-02-26 Anti-HBs (NM) Negative
2025-02-26 Anti-HBs value (NM) <2.0 mIU/mL
[exam finding]
[MedRec]
[surgical operation]
[immunochemotherapy]
The patient is a 74-year-old male with diffuse large B-cell lymphoma (DLBCL), Lugano stage II, undergoing R-CHOP chemotherapy using liposomal doxorubicin. He is currently admitted for suspected neutropenic fever following Cycle 5 of chemotherapy (administered on 2025-06-12). ANC dropped to 968/µL on 2025-06-24, and temperature reached 38.5°C since 2025-06-22. Other comorbidities include type 2 diabetes mellitus, hypertension, and HBV carrier status. Clinical exam and vitals are stable; chest X-ray showed nonspecific right upper lobe infiltrates. No obvious infectious source from urinalysis or GI/GU systems. Empirical antibiotics initiated. Glycemic control is suboptimal (glucose 254 mg/dL on 2025-06-24).
Problem 1. Neutropenic fever post-chemotherapy
Problem 2. Myelosuppression following R-CHOP (Cycle 5)
Problem 3. Hyperglycemia in setting of diabetes and infection (below not posted)
Problem 4. Chemotherapy response and disease status
Problem 5. HBV carrier under chemotherapy
[MedRec]
This is a 74-year-old male with metastatic prostate adenocarcinoma (diagnosed 2022), who has progressed through androgen deprivation, enzalutamide, radiation, and docetaxel/cisplatin, and was started on olaparib in 2025-04 based on FoundationOne NGS. In 2025-05, the patient developed T7–T11 spinal cord compression and paraplegia, requiring emergent decompressive laminectomy with significant intraoperative bleeding and persistent postoperative paraplegia. Palliative radiotherapy was halted due to severe pancytopenia. He was admitted on 2025-06-23 for supportive care, pain management, and hospice planning. Current labs show pancytopenia (HGB 7.3 g/dL, PLT 44 x10³/uL, WBC 2.97 x10³/uL), hypoalbuminemia (2.7 g/dL), and hypocalcemia (1.81 mmol/L), but preserved renal (Cr 1.14 mg/dL, eGFR 66.93 mL/min/1.73m²) and liver function (ALT 18 U/L, AST 17 U/L) (labs 2025-06-23). He is receiving multimodal analgesia including Duragesic (fentanyl) patch, OxyContin (oxycodone), and PRN Morphine, with adequate but guarded control.
Problem 1. Advanced metastatic prostate adenocarcinoma with spinal cord compression
Objective
Assessment
Recommendation
Problem 2. Severe anemia and thrombocytopenia (transfusion-dependent pancytopenia)
Problem 3. Pain management in paraplegic terminal cancer patient
Problem 4. Nutritional and metabolic derangements
[Medication Reconciliation]
Date: 2025-06-24 Patient: 74-year-old male with metastatic prostate adenocarcinoma, extensive bony metastases, post-spinal cord compression (T7–T11) with paraplegia Current Status: Admitted 2025-06-23 for pain control and hospice evaluation; receiving multiple supportive medications.
Summary of Discrepancies and Recommendations:
Additional Monitoring Suggestions:
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
This is a 69-year-old male with a diagnosis of moderately differentiated right buccal mucosa squamous cell carcinoma (pT3N0M0, Stage III) status post wide excision, selective neck dissection, and split-thickness skin graft on 2025-04-11. He is currently undergoing concurrent chemoradiotherapy with weekly cisplatin since 2025-05-15 and has received 5000 cGy/25 fractions as of 2025-06-19. He presents with neutropenic sepsis secondary to right lower lobe pneumonia, with complications including grade 3 neutropenia, thrombocytopenia, elevated CRP, and ongoing dizziness. His performance status is ECOG 2 (2025-06-24), and he remains hemodynamically stable on current therapy.
Problem 1. Neutropenic Sepsis with Aspiration Pneumonia
Problem 2. Head and Neck Cancer (Right Buccal SCC pT3N0M0, Stage III) s/p Surgery and Ongoing CCRT
Problem 3. Myelosuppression (Neutropenia and Thrombocytopenia)
Problem 4. Electrolyte Abnormalities and Malnutrition
Problem 5. Cardiovascular Status and LV Dysfunction
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
[note]
Non-Hodgkin lymphoma ESHAP (etoposide methylprednisolone cytarabine ciSplatin) - 20250623 - https://www.eviq.org.au/haematology-and-bmt/lymphoma/other-b-cell-lymphoma/124-eshap-etoposide-methylprednisolone-cytarabine
Chemotherapy regimen: ESHAP - 20250623 - https://hivclinic.ca/main/drugs_chemo_files/ESHAP.pdf
This 78-year-old man has a complex medical history including:
Problem 1. Relapsed Classical Hodgkin Lymphoma
Problem 2. Cytopenia – Anemia and Myeloproliferation
Problem 3. Cardiopulmonary Function and Comorbid COPD (not posted)
Problem 4. Cardiovascular and Thromboembolic Risks
Problem 5. Dermatologic Issue – Scalp Eczema (not posted)
[exam finding]
[MedRec]
2025-05-23 ~ 2025-05-31 POMR Hemato-Oncology Xia HeXiong
2025-04-19 ~ 2025-04-25 POMR Chest Medicine Huang GuoLiang
2025-02-26 ~ 2025-03-03 POMR Ear Nose Throat Huang TongCun
2025-02-11 ~ 2025-02-20 POMR Ear Nose Throat Huang TongCun
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
This is a 71-year-old male with an oncologic history of recurrent SCC involving the right oropharynx, tongue, and palate (initial stage cT4aN2bM0, post multiple surgeries and CCRT). Despite extensive treatments including tongue/palate resections, neck dissections, free flap and STSG reconstructions, and CCRT (2023-07 to 2023-09), recent PET (2025-05-12) and MRI (2025-05-07) suggest multifocal local recurrence involving the right oropharyngeal wall, tongue, and mouth floor. He is undergoing neoadjuvant chemotherapy with PF4 regimen (cisplatin + 5-FU), started 2025-05-26 and again administered on 2025-06-20. Comorbidities include CAD post-CABG (2023-02), type 2 diabetes, hypertension, dyslipidemia, GERD, and chronic otitis media. Current clinical status is stable (ECOG 2), vital signs are acceptable, and labs show normal hepatic and renal function, but intermittent hyperglycemia is noted.
Problem 1. Recurrent right oropharyngeal and oral SCC, post CCRT and multiple resections
Problem 2. Glycemic instability in type 2 diabetes mellitus
Problem 3. Cardiovascular disease post-CABG
Problem 4. Hematological tolerance during chemotherapy (not posted)
Problem 5. Gastrointestinal symptoms and mucosal protection (not posted)
This 71-year-old male with a complex history of recurrent, multifocal squamous cell carcinoma (SCC) of the oropharynx and oral cavity (right tongue, floor of mouth, and palate) has undergone multiple surgeries including wide excisions, STSG, free flap reconstruction, and radiotherapy. Imaging (PET 2025-05-12, MRI 2025-05-07) confirms new recurrent disease in the oropharynx and oral cavity. As of 2025-05-26, he remains in stable condition, planned for further chemotherapy. Renal function is preserved (CCr 82.3 mL/min on 2025-05-24), and hematologic parameters show no major cytopenias despite chronic inflammation (CRP peaked at 8.4 mg/dL on 2025-04-18, now downtrending). Blood glucose is moderately elevated with known type 2 DM, previously managed with Tresiba (insulin degludec) and oral agents.
Problem 1. Locoregionally Recurrent Multifocal Oral and Oropharyngeal Squamous Cell Carcinoma
Problem 2. Renal Function and Chemotherapy Clearance (not posted)
Problem 3. Hematologic and Inflammatory Status (not posted)
Problem 4. Type 2 Diabetes and Glycemic Control
Problem 5. Cardiovascular Comorbidities and Onco-cardiology Risk
[exam findings]
[MedRec]
[consultation]
2024-12-02
2024-10-21
2024-09-02 General and Gastroenterological Surgery
2024-07-18 General and Gastroenterological Surgery
[surgical operation]
[chemotherapy]
The patient has unresectable, low-grade pseudomyxoma peritonei (PMP) confirmed on pathology (2024-04-25), with disease progression noted on recent CT (2025-06-07) showing enlargement of pelvic cystic lesion (from 10.7 cm to 13.03 cm) and worsening cancerous peritonitis. She had previously completed multiple cycles of systemic (modified FOLFOX6 and 5-FU) and intraperitoneal chemotherapy (IP 5-FU), achieving temporary disease control. However, due to radiologic progression and rising CEA/CA19-9 levels, she was shifted to FOLFIRI regimen starting on 2025-06-19.
Her performance status remains preserved (ECOG 1), with stable hemodynamics and tolerable side effects from the new chemotherapy regimen. There is no hepatic, renal, or hematologic toxicity at present. No evidence of metastases on bone scan (2025-06-06). Mild right-sided costovertebral angle tenderness may reflect hydronephrosis or chronic renal scarring. She remains functionally stable.
Problem 1. Pseudomyxoma peritonei (mucinous carcinoma peritonei), in progression
Problem 2. Hematologic status under chemotherapy
Problem 3. Hepatorenal function and electrolyte status
Problem 4. Gastrointestinal tolerance and chemotherapy side effects
This is a 64-year-old woman with low-grade pseudomyxoma peritonei (PMP), diagnosed via laparoscopy and biopsy on 2024-04-25, presenting as stage IV (cTxNxM1) mucinous carcinoma peritonei. The disease is deemed unresectable, with cytoreductive surgery and HIPEC not suitable due to extensive peritoneal seeding (PCI 29/39 on 2024-09-04). She has since undergone systemic chemotherapy with modified FOLFOX6 and intraperitoneal 5-FU, showing stable disease on serial imaging (CT 2025-03-22).
Recent tumor markers (CEA/CA19-9) show stabilization or mild fluctuation after prior elevation. Vital signs are stable, and no current evidence of end-organ damage or treatment-limiting toxicity. Current therapy appears tolerable and aligned with disease biology and clinical course.
Problem 1. Low-grade pseudomyxoma peritonei (mucinous carcinoma peritonei)
Problem 2. Hematologic tolerance to chemotherapy
Problem 3. Hepatic and renal function during chemotherapy
Problem 4. Cardiopulmonary monitoring and performance status
[Pseudomyxoma Peritonei: Stable Disease and Improving Liver Function]
Lab results indicate improvement in liver function, with ALT and AST levels returning toward the normal range.
2024-09-19 ALT 38 U/L
2024-09-13 ALT 46 U/L
2024-09-05 ALT 67 U/L
2024-09-19 AST 46 U/L
2024-09-13 AST 53 U/L
2024-09-05 AST 73 U/L
The CT scan (2024-08-30) shows stable carcinomatosis (pseudomyxoma peritonei) compared to the prior scan from 2024-03-27, following chemotherapy.
CEA and CA199 levels have remained relatively stable at 15-20 ng/mL and 300-350 U/mL, respectively, suggesting stable disease.
2024-08-29 CEA 15.41 ng/mL
2024-07-12 CEA 20.97 ng/mL
2024-06-24 CEA 18.55 ng/mL
2024-04-24 CEA 23.27 ng/mL
2024-03-11 CEA 19.14 ng/mL
2024-02-17 CEA 15.01 ng/mL
2024-01-09 CEA 26.36 ng/mL
2024-08-29 CA199 285.93 U/mL
2024-07-12 CA199 352.43 U/mL
2024-06-24 CA199 358.44 U/mL
2024-04-24 CA199 364.88 U/mL
2024-03-11 CA199 346.21 U/mL
2024-02-17 CA199 299.32 U/mL
2024-01-09 CA199 422.77 U/mL
No medication issues were identified.
[normal lab results clear for FOLFOX regimen administration]
Lab results on 2024-06-03 showed no significant abnormalities.
These normal results allow for the planned FOLFOX regimen to proceed without contraindication.
Additionally, no discrepancies were found in the patient’s medication list.
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
This 71-year-old woman with diffuse large B-cell lymphoma (DLBCL), germinal center B-cell (GCB) subtype, Lugano stage III, continues chemotherapy with R-CHOP, receiving 6 cycles as of 2025-06-19. The overall status is stable with ECOG 1 and adequate organ function. She experienced neutropenic fever after Cycle 5 but recovered. Her recent labs (2025-06-19) show resolution of neutropenia, stable anemia, and no evidence of acute liver, renal, or infectious complications. She remains on Vemlidy (tenofovir alafenamide) for chronic hepatitis B prophylaxis and is tolerating chemotherapy.
Problem 1. Diffuse Large B-Cell Lymphoma, GCB Subtype (Stage III, CD10+, Ki-67 >90%)
Problem 2. Chemotherapy-Related Cytopenias (Neutropenia and Anemia)
Problem 3. Infection Risk and Status Post-Neutropenic Fever (not posted)
Problem 4. Hepatitis B Reactivation Risk Under Rituximab (not posted)
Problem 5. Diabetes Mellitus and Metabolic Monitoring (not posted)
Problem 1. Agranulocytosis secondary to cancer chemotherapy
Problem 2. Diffuse Large B-cell Lymphoma (DLBCL), GCB subtype, Lugano stage III
Problem 3. Hypokalemia and Hypomagnesemia
Problem 4. Thrombocytopenia
This is a 71-year-old woman diagnosed with diffuse large B-cell lymphoma (DLBCL), germinal center B-cell (GCB) subtype, stage III (PET 2024-12-13), undergoing chemotherapy with R-CHOP (C3 administered on 2025-03-19). She has chronic hepatitis B (anti-HBc positive, HBsAg negative) and is on Vemlidy (tenofovir alafenamide) for HBV prophylaxis.
Problem 1. Diffuse Large B-Cell Lymphoma (DLBCL) - Treatment and Response
Problem 2. Hypertension and Cardiovascular Risk
Problem 3. Blood Glucose Variability and Metabolic Control (not posted)
Problem 4. Hematologic Status and Neutropenia Risk
Problem 5. Chronic Pharyngitis and Laryngopharyngeal Reflux (LPR) (below not posted)
Problem 6. Hepatitis B Carrier Status
Final Notes
[lab data]
Body weight
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
Subjective
The patient is a 43-year-old woman, recently discharged post first cycle of FOLFIRINOX chemotherapy (2025-03-21 to 2025-03-23) for stage IIIA adenocarcinoma of the ampulla of Vater (post-Whipple operation on 2025-02-12).
Post-FOLFIRINOX (C1D1) Chemotherapy – Adverse Reaction Evaluation
Current medications:
The patient reports:
Objective
Assessment
Plan / Recommendation
This 43-year-old woman is undergoing adjuvant chemotherapy for adenocarcinoma of the ampulla of Vater, staged pT2N1(cM0) IIIA after pancreatoduodenectomy and partial gastrectomy (2025-02-12). She is currently admitted for her fourth chemotherapy cycle (C3D15) of mFOLFIRINOX. Chemotherapy dates include: 2025-03-20 (C1D1), 2025-04-14 (C1D15), 2025-04-30 (C2D1), 2025-05-14 (C2D15), 2025-06-02 (C3D1), and now 2025-06-19 (C3D15). Her treatment course has been complicated by episodes of neutropenia, anemia, mild transaminitis, progressive hypoalbuminemia, and weight loss, necessitating nutritional and psychological support. Her current ECOG performance status is 0.
On 2025-06-19, prior to chemotherapy, labs revealed normothermia and stable vitals. There were mild hypokalemia (K 3.3 mmol/L), hypocalcemia (Ca 1.85 mmol/L), hypoalbuminemia (3.3 g/dL), anemia (Hb 8.9 g/dL), thrombocytopenia (PLT 115 ×10^3/uL), and borderline leukopenia. Parenteral nutrition, hydration, and electrolyte replacement were prescribed.
Problem 1. Adenocarcinoma of ampulla of Vater, pT2N1(cM0) stage IIIA
Problem 2. Chemotherapy-related hematologic toxicity (anemia, thrombocytopenia, leukopenia)
Problem 3. Electrolyte and nutritional disturbances (hypoalbuminemia, hypokalemia, hypocalcemia)
Problem 4. Insomnia and emotional distress
Problem 5. Nephro-hepatic function surveillance (not posted)
[Bedside Visit and Patient Education]
Date & Time of Visit: 2025-03-24 at approximately 13:20
Location: Bedside visit; the patient’s husband was present in the room.
Assessment & Intervention:
I advised the following:
note: The patient has two children - one in second grade and one in fifth grade. The younger one is more mischievous.
[Bedside Visit and Patient Education]
Date & Time of Visit: 2025-03-21 at approximately 11:45
Location: Patient’s room; patient was lying in bed and accompanied by her husband.
Assessment & Intervention:
Observation:
[Patient Evaluation]
The patient is a 43-year-old female with adenocarcinoma of the ampulla of Vater, mixed pancreatobiliary and intestinal type, stage IIIA (pT2N1M0), post-Whipple procedure (2025-02-12). The treatment plan for her is FOLFIRINOX chemotherapy (scheduled on 2025-03-21). Her recovery has been complicated by postoperative intra-abdominal fluid collection requiring pigtail drainage (2025-02-26), as well as significant psychological distress related to her illness.
Problem 1. Adenocarcinoma of Ampulla of Vater, Post-Whipple Procedure
Problem 2. Postoperative Intra-Abdominal Fluid Collection
Problem 3. Postoperative and Chemotherapy-Related Hematological Abnormalities
Problem 4. Psychological Distress and Suicidal Ideation
Problem 5. Postoperative Nutritional Deficiencies and GI Symptoms
[MedRec]
[MedRec]
[Betmiga (mirabegron) tube feeding]
Betmiga 50mg/tab (mirabegron) is not recommended for tube feeding.
Rationale for Betmiga:
Mirabegron (Betmiga) 50mg tablets are formulated as extended-release (ER) tablets. Crushing or breaking extended-release formulations destroys their controlled-release mechanism. This can lead to:
Therefore, for patients requiring tube feeding, Betmiga ER tablets should not be crushed.
Recommendations for Alternatives for Tube Feeding:
Urotrol FC 15mg/tab (propiverine) and Vesicare FC 5mg/tab (solifenacin) are in the same ATC category (G04BD - Drugs for urinary frequency and incontinence) and are typically used for overactive bladder. Both are generally considered suitable for administration via tube feeding:
Important Considerations:
[Xtandi 40mg/tab (Enzalutamide) - tube feeding]
Xtandi (enzalutamide) capsules, as the manufacturer explicitly states that the capsules should not be chewed, dissolved, or opened, and tablets should not be cut, crushed, or chewed.
[exam finding]
[MedRec]
[consultation]
[immunochemotherapy]
2025-06-18 - pembrolizumab 200mg NS 100mL 30min
2025-05-10 ~ 2025-06-02 - Iressa (gefitinib 250mg) 1# QD
This is a 75-year-old woman with left upper lobe (LUL) lung adenocarcinoma, moderately differentiated, stage IVB (cTxN2-3M1c1 per PET 2025-05-21), complicated by multiple brain metastases (MRI 2025-05-10; CT 2025-05-12), EGFR wild-type (2025-05-16), ALK/ROS1 negative (2025-06-02), PD-L1 TPS 90% (2025-06-02). She had previously received palliative radiotherapy to the brain (3000cGy/10 fractions from 2025-05-22 to 2025-06-04) and a short trial of self-paid Iressa (gefitinib 250mg QD from 2025-05-12 to 2025-06-06). She is currently undergoing her first cycle of immunotherapy with Keytruda (pembrolizumab) 200mg (C1 on 2025-06-18). Clinical condition is ECOG PS 4, with persistent left-sided weakness and no current seizures or fever. Labs on 2025-06-18 showed normonatremia (Na 135 mmol/L), borderline hypokalemia (K 3.0 mmol/L), anemia (Hb 8.9 g/dL), preserved renal and liver function.
Problem 1. Metastatic LUL adenocarcinoma (cTxN2-3M1c1, PD-L1 high)
Problem 2. Neurologic impairment from brain metastases
Problem 3. Anemia (Hb <9.0 g/dL)
Problem 4. Electrolyte imbalance (hypokalemia, borderline hyponatremia)
Problem 5. Functional decline and poor performance status (ECOG 4)
[Mild hypokalemia associated with steroid use]
Mild hypokalemia associated with steroid use, particularly glucocorticoids like Compesolon (prednisolone), is due to their mineralocorticoid activity, which can lead to renal potassium wasting. Here’s the step-by-step rationale:
Prednisolone, while primarily a glucocorticoid, still retains some mineralocorticoid effect, especially at moderate to high doses.
This effect promotes renal sodium retention and potassium excretion in the distal nephron (via ENaC activation and Na⁺/K⁺ exchange).
The end result is hypokalemia, especially in patients who are:
In this case, the patient is on prednisolone 10 mg BID (equivalent to 40 mg hydrocortisone per day), which is sufficient to cause mild K⁺ loss over days, especially in a fragile, hyporexic elderly patient.
Supporting reference:
Therefore, the ongoing Const-K (potassium chloride) supplementation is appropriate, and potassium trends should continue to be monitored.
[Tagrisso (osimertinib)]
Use of Tagrisso (osimertinib) in this patient is not appropriate, based on the current molecular profile and guideline-based indications. Here’s a structured analysis:
Summary:
This is a 75-year-old female with:
Commentary on Osimertinib Use
In summary:
Osimertinib is not appropriate for this patient due to lack of EGFR mutation. Treatment with pembrolizumab is guideline-concordant.
[The use of Iressa (gefitinib 250mg QD from 2025-05-10 to 2025-06-02)]
The use of Iressa (gefitinib 250mg QD from 2025-05-10 to 2025-06-02) in this case appears to be a provisional, off-label, and ultimately inappropriate treatment, though contextually understandable as an urgent empirical measure. Here’s the stepwise analysis:
Conclusion
The 2025-05-10 to 2025-06-02 course of Iressa:
[exam finding]
[MedRec]
[Patient Summary]
Demographics: 62-year-old male with no prior known systemic diseases; regular user of Chinese herbal medicine; non-smoker.
Presentation: Presented on 2025-05-16 with:
Diagnosis:
Hospital Course:
Planned Treatment:
Prognosis:
[Subjective]
medication adherence and procedure readiness
[Objective]
recent treatment and monitoring
[Assessment]
medication adherence confirmed; CABG schedule under reconsideration
[Plan / Recommendation]
pharmacist support for safe transition toward surgery or modified plan
[treatment]
Based on the patient data provided, the treatment plan is appropriate and evidence-based for a patient with:
A. Key Insight / Summary
This is a 62-year-old male with new-onset NSTEMI, found to have severe 3-vessel disease with:
Cardiac enzymes (hs-TnI) peaked to 46880.2 pg/mL on 2025-05-17, then trended down to 106.8 pg/mL by 2025-05-26, consistent with recent myocardial injury and stabilization.
Echocardiography (2025-05-19) showed preserved systolic function (LVEF 55%) with trivial MR/TR and no wall motion abnormalities.
He is planned for elective total arterial coronary artery bypass grafting (CABG) on 2025-07-09, after cardiology consultation and shared decision-making, with reasonable surgical risk and preserved function.
B. Problem-Oriented Deliberation
Problem 1. Acute Coronary Syndrome (NSTEMI) and 3-Vessel CAD
Problem 2. Antiplatelet and Secondary Prevention
Problem 3. Electrolyte and Volume Status
Problem 4. Thyroid Function
C. Overall Assessment of Treatment Plan
[Why CABG? Why not balloon angioplasty or stenting (PCI)?]
In this simulated patient, balloon angioplasty or stenting (PCI) was not chosen as definitive treatment because anatomic and clinical factors strongly favor CABG. Here’s a detailed, evidence-based explanation:
A. Key Clinical and Angiographic Findings Against PCI
B. Why PCI is Suboptimal Here
C. Why CABG Is the Better Option
D. Guidelines Support
According to:
“CABG is recommended over PCI in patients with multivessel CAD and a high SYNTAX score (≥23), particularly if complete revascularization is unlikely with PCI.”
E. Summary
Balloon angioplasty or stenting was not performed because:
Therefore, CABG is the more appropriate and guideline-concordant choice in this patient.
[exam finding]
[MedRec]
This is a 92-year-old female with metastatic colon cancer (lung metastases, malignant ascites), ECOG 4, referred from Cardinal Tien Hospital and not yet started on oncologic treatment. She presents with acute abdominal pain, vomiting, and functional decline. Significant comorbidities include heart failure, old cerebrovascular accident, diabetes, hypertension, and hypothyroidism. Clinical findings suggest possible concurrent infection (elevated CRP, leukocytosis, pyuria, bacteriuria, and positive urine yeast), ileus, and hypoalbuminemia. She is on empirical antibiotics and supportive care. Management complexity is high due to age, frailty, functional status, and multi-organ vulnerability.
Problem 1. Metastatic colorectal cancer with malignant ascites and ECOG 4
Problem 2. Possible urinary tract infection with fungal component
Problem 3. Ileus and gastrointestinal obstruction
Problem 4. Acute inflammation and systemic stress response
Problem 5. Hyponatremia and early renal impairment (not posted)
Problem 6. Polypharmacy and sedation risk (not posted)
[lab data]
2024-11-27 HBV DNA PCR Target Not Detected IU/mL
2024-10-08 HIV Ab-EIA Nonreactive
2024-10-08 Anti-HIV Value 0.06 S/CO
2024-10-07 HCV RNA PCR (quan) 4750000 IU/mL
2024-10-01 Anti-HBc Reactive
2024-10-01 Anti-HBc Value 2.29 S/CO
2024-10-01 Anti-HBs 68.29 mIU/mL
2024-10-01 EBV DNA (quan) 20100 IU/mL
2024-09-30 HBsAg Nonreactive
2024-09-30 HBsAg Value 0.34 S/CO
2024-09-30 Anti-HCV Reactive
2024-09-30 Anti-HCV Value 23.32 S/CO
[exam finding]
[MedRec]
[radiotherapy]
[chemotherapy]
This is a 58-year-old man with nasopharyngeal carcinoma (NPC), staged as cT4N3M1 (Stage IVC) due to intracranial extension and distant lymph node metastases (MRI 2024-09-26, PET 2024-09-27). Pathology confirms non-keratinizing undifferentiated NPC (WHO Type 2B) (2024-09-18). He underwent induction chemotherapy with TPF starting 2024-10-01 and transitioned to concurrent chemoradiotherapy (CCRT) with weekly cisplatin beginning 2025-02-03. Locoregional tumor remained stable on MRI (2025-06-12), with some lymph node regression. However, the clinical course is complicated by anemia, fluctuating liver function, hypoalbuminemia, weight loss, syncope episodes, and a new infected leg wound affecting treatment compliance.
Problem 1. Locally advanced nasopharyngeal carcinoma, cT4N3M1 (stage IVC)
Problem 2. Poor oral intake and malnutrition
Problem 3. Anemia
Problem 4. Elevated liver enzymes and viral hepatitis
Problem 5. Pain and insomnia
[HCV] (not posted)
While initiating direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV) infection is standard of care, immediate initiation may not be the best choice in this patient’s current clinical context due to several integrated reasons:
In summary, delaying DAA is not due to negligence but a strategic prioritization of the patient’s acute oncologic and infection control needs. Reassessment should occur after nutritional and wound stabilization or once systemic cancer therapy pauses or completes.
[exam finding]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
[Subjective]
chemotherapy-related adverse effect
communication and follow-up
[Objective]
adverse drug reaction
current medications (2025-06-16 prescribed)
[Assessment]
paclitaxel hypersensitivity reaction
[Plan / Recommendation]
optimize paclitaxel administration
monitoring and coordination
The patient is a 59-year-old male with a diagnosis of moderately differentiated squamous cell carcinoma of the right hilar lung, clinical stage cT4N3M0 (stage IIIC), presenting initially with chronic cough and weight loss. He is receiving concurrent chemoradiotherapy (CCRT) with weekly paclitaxel + cisplatin. Pathology confirmed squamous histology (biopsy 2025-05-15). PD-L1 is negative (TPS 0%), and no EGFR/ALK mutation is present. Imaging (PET 2025-05-19, CT 2025-04-15) confirms bulky right hilar and mediastinal lymphadenopathy with no distant metastases. He has emphysematous COPD and reflux esophagitis. He tolerated 2 cycles of chemotherapy with manageable adverse effects but developed an infusion reaction on 2025-06-11.
Problem 1. Primary Lung Cancer (SqCC, cT4N3M0, stage IIIC)
Problem 2. Chemotherapy-Related Hypersensitivity (Paclitaxel, 2025-06-11)
Problem 3. Anemia
Problem 4. COPD with Emphysema
Problem 5. Nutritional Risk and Cancer Cachexia
Problem 6. Psychosocial and Economic Burden
[anemia] (not posted)
The labs:
→ This pattern is not consistent with iron overload, despite the high ferritin.
Interpretation:
This pattern is most consistent with anemia of chronic inflammation (ACI), sometimes called anemia of chronic disease (ACD).
Why it is not classic iron deficiency anemia:
This patient, however, has elevated ferritin and low transferrin saturation, which is characteristic of inflammatory anemia (like that associated with cancer) — not classic IDA.
Conclusion:
[albumin-bound paclitaxel (nab-paclitaxel)] (not posted)
Albumin-bound paclitaxel (nab-paclitaxel) is included in the NCCN Clinical Practice Guidelines for Non-Small Cell Lung Cancer (NSCLC) as a recommended regimen for squamous cell carcinoma in specific contexts.
Based on the NCCN Guidelines Version 5.2024 and continuing into 2025:
Conclusion:
[exam finding]
Endoscopic Retrograde Cholangiopancreatography, ERCP - Findings - Duodenum - No ulcer is found at the bulb and second portion of duodenum. - Papila - The major papilla looks negatvie. - Pancreatic duct - not done - Common bile duct - Selective cannulation with C duct is done with clever cut papillotome and the cholangiography showed marked dilated proximal biliary tree and a strictiure segment about 3-4 cm at the distal CBD. - Intrahepatic bile duct - The Bil IHDs are not dilated. - Gall bladder - GB is not opacified. - Others - Short mucosal breaks noticed at the lower esophagus. - Management - Standard endoscopic sphincterotomy (Olympus Co.) is done and followed by a 10 Fr. 7 cm straight stent is placed for free drainage. - Diagnosis - Distal CBD stricture s/p EST and 10 Fr 7 cm stent placement
[chemotherapy]
This 73-year-old male with metastatic pancreatic adenocarcinoma (T4N2M1, stage IV) complicated by lung, liver, lymph node metastases, and obstructive cholangitis (post-ERBD), presents with acute decompensation characterized by:
The patient is DNR with hospice referral pending. He is managed with IV antibiotics (Tapimycin), transfusions, hyperkalemia rescue (e.g., sodium bicarbonate), and supportive care.
Problem 1. Acute Kidney Injury on CKD stage 3
Problem 2. Electrolyte Imbalances - Severe Hyperkalemia, Hyponatremia
Problem 3. Anemia and Thrombocytopenia
Problem 4. Sepsis and Acute Respiratory Compromise
Problem 5. Advanced Pancreatic Cancer with Metastases
[exam finding]
[MedRec]
[consultations]
2024-10-14 Oral and maxillofacial surgery
2024-08-16 Thoracic surgery
2024-06-18 Dermatology
2024-06-18 Neurosurgery
[surgical operation]
[immunochemotherapy]
This 59-year-old woman with stage IVA right lower lobe lung adenocarcinoma (pT1c, pN1, cM1c), complicated by pontine metastasis and prior obstructive hydrocephalus (VP shunt on 2024-06-25), remains on systemic therapy. She has received multimodal chemotherapy including pemetrexed/cisplatin, docetaxel/pembrolizumab, paclitaxel/carboplatin/pembrolizumab, and currently pembrolizumab with Mvasi (bevacizumab biosimilar).
Recent labs show anemia (HGB 9.4), thrombocytopenia (PLT 128), and elevated tumor markers (CEA 83.98 ng/mL, CA199 71.64 U/mL as of 2025-05-30).
CT and chest sono (2025-05-23 and 2025-06-17) confirm persistent encapsulated right pleural effusion, suspicious for pleural metastasis. Brain MRI (2025-03-12) shows stable pontine metastasis.
She is admitted for C2 immunotherapy and PET scan evaluation.
Problem 1. Right Lower Lobe Lung Adenocarcinoma, Stage IVA with Pleural and Brain Metastases
Problem 2. Anemia and Thrombocytopenia under Immunochemotherapy (below not posted)
Problem 3. Right-Sided Encapsulated Pleural Effusion and Empyema Sequelae
Problem 4. Chronic Hepatitis B (Anti-HBc Positive, HBsAg Negative)
Problem 5. Neurological Sequelae from Pontine Metastasis and Post-VP Shunt
Problem 6. Pain and Sleep Disturbance
Key Summary Since 2024-12-17
Problem 1: Worsening Anemia (Normocytic Normochromic)
Problem 2: Persistent Right Pleural Effusion & Lung Disease
Problem 3: Bone Scan Progression – L-Spine Lesions
Active Medication Review (below not posted)
Summary of Key Changes Since 2024-12-17
| Issue | 2024-12-17 | 2025-03-10 | Trend |
|---|---|---|---|
| Anemia (HGB g/dL) | ~8.5-9.0 | 7.9 | ↓ Worsening |
| Pleural Effusion | Present | Persistent | No Resolution |
| Bone Scan (L-Spine) | Mild Uptake | Increased Uptake | Possibly Worse |
| Chemotherapy | Ongoing | Adjustments in paclitaxel dosing (80%-90%) | Dose Adjusted |
| Renal Function (eGFR mL/min) | 105-110 | 106.7 | Stable |
| Liver Function (AST/ALT U/L) | Normal | Stable | Stable |
Next Steps
Conclusion: The patient remains stable but exhibits worsening anemia, persistent lung abnormalities, and progressive bone scan changes, requiring targeted interventions and monitoring.
[Patient Summary]
The 59-year-old female patient presents with stage IVA right lower lobe lung adenocarcinoma (pT1c, pN1, cM1c), confirmed with metastatic lesions involving the left pons and abdominal wall. She has a history of video-assisted thoracoscopic surgery (VATS) for right middle lobe wedge resection, right lower lobectomy, and radical lymph node dissection (2024-05-14).
[Problem-Oriented Comments]
[Medication Review]
[exam finding]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
The patient is a 63-year-old woman with FIGO stage IIIC1ii endometrial adenocarcinoma (grade 3, pT2N1aM0) status post staging surgery on 2025-02-24, receiving concurrent chemoradiotherapy with paclitaxel plus cisplatin. She completed 4 cycles of chemotherapy uneventfully (C1 on 2025-03-25, C2 on 2025-04-29, C3 on 2025-05-20, and C4 on 2025-06-17). Radiation (external beam and vaginal cuff brachytherapy) began on 2025-04-01. The clinical course remains stable with no acute toxicity, preserved ECOG PS 1, no signs of infection or tumor progression, and resolving CA-125 from 44.6 (2025-02-15) to 5.510 U/mL (2025-06-09). Labs show anemia (Hb 9.9 g/dL on 2025-06-16), marginal renal function (eGFR 49.17), and resolved neutropenia. Overall, she is tolerating therapy with supportive care, including magnesium and antiemetics.
Problem 1. Endometrial adenocarcinoma (FIGO IIIC1ii, pT2N1aM0, grade 3)
Problem 2. Anemia
Problem 3. Renal function (cisplatin nephrotoxicity risk)
Problem 4. Sleep disturbance and prior benzodiazepine use (not posted)
[lab data]
2024-07-16 HBsAg Nonreactive
2024-07-16 HBsAg Value 0.43 S/CO
2024-07-16 Anti-HBs 2.64 mIU/mL
2024-07-16 Anti-HBc Reactive
2024-07-16 Anti-HBc Value 5.82 S/CO
2024-03-29 HBsAg (NM) Negative
2024-03-29 HBsAg Value (NM) 0.458
2024-03-29 Anti-HBc (NM) Positive
2024-03-29 Anti-HBc Value (NM) 0.007
2024-03-29 Anti-HCV (NM) Negative
2024-03-29 Anti-HCV Value (NM) 0.04
[exam finding]
[MedRec]
[consultation] (not completed)
[surgical operation]
[immunochemotherapy]
This is a 46-year-old man with locally advanced adenocarcinoma of the splenic flexure of the colon (pT4bN1bM1a, Stage IVC) with left supraclavicular lymph node, liver, and peritoneal metastases, complicated by recurrent adhesive small bowel obstruction, enterocutaneous fistula, and progressive carcinomatosis. He has undergone multiple laparotomies and bowel bypass procedures, with current chemotherapy based on modified FOLFIRI (Avastin held temporarily). Latest PET on 2025-06-10 revealed progressive liver and peritoneal FDG activity. He currently exhibits stable vital signs, well-controlled pain, and Grade 1 fatigue and diarrhea under chemotherapy. Lab data show mild anemia, normal renal/liver function, and no significant electrolyte disturbance.
Problem 1. Metastatic colon adenocarcinoma (stage IVC, pT4bN1bM1a)
Problem 2. Enterocutaneous fistula and surgical wound complication
Objective
Assessment
Recommendation
Problem 3. Small bowel obstruction status post multiple surgeries
Problem 4. Cancer cachexia and nutritional support
Problem 5. Pain management
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
This 75-year-old woman with stage IV peritoneal mesothelioma (cT4N2M1, ECOG 3) complicated by liver metastasis, carcinomatosis, and malignant ascites, has received three cycles of immunochemotherapy (Atezolizumab, Bevacizumab, Pemetrexed, Carboplatin) between 2025-03-27 and 2025-05-20 with fair tolerance. She now presents with abdominal distention and lower limb twitching. Despite intermittent febrile episodes and mild lab abnormalities (e.g., normocytic anemia, hypoalbuminemia, mild hyponatremia), her imaging suggests partial disease response with stable to regressing carcinomatosis. Her performance status and lab stability currently support continuation of systemic therapy. Ascites is persistent and symptomatic, with analysis planned.
Problem 1. Peritoneal mesothelioma with liver metastasis, carcinomatosis, and malignant ascites (cT4N2M1, stage IV, ECOG 3)
Problem 2. Normocytic anemia
Problem 3. Recurrent malignant ascites
Problem 4. Dermatologic infection (Carbuncle)
Problem 5. Hyponatremia and electrolyte imbalance (not posted)
[exam finding]
[MedRec]
[consultation]
[immunochemotherapy]
The patient is a 51-year-old male with stage IVB right upper lobe pulmonary adenocarcinoma (cT4N3M1c2, AJCC 9th ed.) confirmed by liver biopsy on 2024-12-27. He presents with progressive dyspnea since 2025-06-12, now associated with right-sided pleural effusion, leukocytosis, anemia, and new bone metastases. Disease progression is evident radiologically (bone scan 2025-06-13; CXR 2025-06-14) and biochemically (CEA rising, CRP 16.9 mg/dL on 2025-06-12). The patient is currently receiving inpatient care, on empiric antibiotics, symptomatic treatments, and pigtail drainage. ECOG performance status is 2. Treatment with pemetrexed + cisplatin chemotherapy (last cycle 2025-05-09) likely no longer effective.
Problem 1. Progressive metastatic lung adenocarcinoma (pleura, bone, liver)
Problem 2. Right pleural effusion with dyspnea
Problem 3. Bone metastases
Problem 4. Anemia and leukocytosis (not posted)
Problem 5. Hyponatremia and electrolyte imbalance (not posted)
[exam finding]
[MedRec]
[chemotherapy]
This 74-year-old man with myelodysplastic syndrome with excess blasts-2 (MDS-EB2), complex karyotype, and refractory pancytopenia is receiving azacitidine (Vidaza) chemotherapy. He is classified as very high-risk per IPSS-R. The clinical course shows persistent transfusion-dependent cytopenias, evolving neutropenia with relative lymphocytosis, critically low platelet counts (PLT <10k), and anemia (HGB <8.5 g/dL), despite multiple transfusions. Bone marrow biopsy on 2025-04-18 showed 24.3% blasts. Current vital signs remain stable with no fever or respiratory distress. Liver and kidney functions are preserved. Current azacitidine cycle started on 2025-06-17. Infection prophylaxis, transfusion support, and further blast monitoring remain critical.
Problem 1. Refractory Pancytopenia with Excess Blasts (MDS-EB2)
Problem 2. Severe Thrombocytopenia with Transfusion Dependence
Problem 3. Normocytic Anemia with Persistent Transfusion Requirement
Problem 4. Absolute Neutropenia with Lymphocyte Predominance
Problem 5. Hematologic Iron Overload Risk
[exam finding]
[MedRec]
[consultation]
This is an 84-year-old woman with left lower lobe lung adenocarcinoma (EGFR L861Q) with brain, liver, bone, and pulmonary metastases (cT4N2bM1c2, stage IVB). She was treated with Giotrif (afatinib) since 2025-05-12 and palliative brain RT from 2025-05-23 to 2025-06-05. She was admitted on 2025-06-13 for worsening general weakness, fatigue, poor appetite, and leukocytosis. The patient also has type 2 diabetes with previously uncontrolled hyperglycemia (max glucose 768 mg/dL on 2025-05-16), chronic hepatitis B on Vemlidy (tenofovir alafenamide), cachexia, prior treated Aspergillus infection, and an extensive list of comorbidities (CHF, COPD, asthma, atrial arrhythmias, CKD risk).
Vital signs are mostly stable without hypoxia, shock, or persistent fever. Active medications include TPN with vitamins/electrolytes, morphine, Sintum (ceftazidime), megestrol, and dexamethasone. Current problems center around cancer progression, infection/inflammation status, functional deterioration, and malnutrition.
Problem 1. Metastatic lung adenocarcinoma (cT4N2bM1c2, EGFR L861Q)
Problem 2. Suspected sepsis without shock
Problem 3. Functional deterioration and cancer-related cachexia
Problem 4. Type 2 diabetes mellitus with prior hyperglycemic crisis
Problem 5. Electrolyte and renal considerations
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
This is a 51-year-old man with stage III squamous cell carcinoma (SCC) of the upper third esophagus (cT3NxM0) confirmed by biopsy (2025-04-23) and imaging (CT 2025-04-28, PET 2025-05-06). He is currently undergoing neoadjuvant concurrent chemoradiotherapy (CCRT) with PF4 regimen since 2025-05-27 and radiotherapy since 2025-05-20. He has a jejunostomy for nutrition and port-A for chemotherapy access. Comorbidities include uncontrolled type 2 diabetes mellitus, recent Klebsiella UTI, aspiration pneumonia, and H. pylori-associated gastritis. Vital signs and labs on 2025-06-15 show hemodynamic stability, normothermia, anemia (Hb 9.7), hypoalbuminemia (Alb 3.1), and adequate renal function (Cr 0.63, eGFR 142.7). Currently ECOG 1.
Problem 1. Esophageal squamous cell carcinoma, stage III, cT3NxM0
Problem 2. Hematologic toxicity and anemia during CCRT
Problem 3. Nutritional status and cachexia
Problem 4. Infection risk: recent Klebsiella UTI and aspiration pneumonia (not posted)
Problem 5. Type 2 diabetes mellitus, poorly controlled (historically) (not posted)
[lab data]
2025-05-14 HBV DNA-PCR (quan) <10 IU/mL
2025-05-08 Anti-HBc Reactive
2025-05-08 Anti-HBc Value 5.67 S/CO
2025-05-08 Anti-HBs 1.01 mIU/mL
2025-05-08 HBsAg Reactive
2025-05-08 HBsAg Value 3.95 S/CO
2025-05-08 Anti-HCV Nonreactive
2025-05-08 Anti-HCV Value 0.13 S/CO
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
This 59-year-old male with squamous cell carcinoma of the upper third of the esophagus (cT2N2M0, Stage III), status post feeding jejunostomy and Port-A insertion on 2025-05-07, is undergoing definitive concurrent chemoradiotherapy (CCRT) with PF regimen and radiation therapy to 50.4 Gy/28 fractions (initiated 2025-05-14). As of 2025-06-13, he is hospitalized for Cycle 2 of chemotherapy (cisplatin + fluorouracil). Current labs reveal preserved renal and hepatic function, microcytic anemia with anisocytosis, neutrophil-predominant leukocytosis, and hyperuricemia. Vital signs are stable, though mild tachycardia was noted on 2025-06-12. No acute complications are reported.
Problem 1. Locally advanced esophageal squamous cell carcinoma (cT2N2M0, Stage III)
Problem 2. Anemia with microcytosis and elevated RDW (not posted)
Problem 3. Renal function and cisplatin safety (not posted)
Problem 4. Hyperuricemia and gout prophylaxis
Problem 5. Cardiopulmonary function and performance status
[lab data]
2024-06-25 HBsAg Nonreactive
2024-06-25 HBsAg Value 0.60 S/CO
2024-06-25 Anti-HBs 32.01 mIU/mL
2024-06-25 Anti-HBc Nonreactive
2024-06-25 Anti-HBc Value 0.22 S/CO
2023-02-10 Anti-HBc Nonreactive
2023-02-10 Anti-HBc Value 0.60 S/CO
2023-02-10 Anti-HBs 32.66 mIU/mL
2023-02-10 Anti-HCV Nonreactive
2023-02-10 Anti-HCV Value 0.05 S/CO
2023-02-10 HBsAg Nonreactive
2023-02-10 HBsAg Value 0.40 S/CO
[exam findings]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
This 68-year-old woman with FIGO stage IV endometrioid adenocarcinoma (initially stage IB, now with confirmed lung metastasis) has undergone extensive treatment including staging surgery (2023-02-01), CCRT with cisplatin and radiotherapy (2023-03 to 2023-04), followed by paclitaxel/carboplatin chemotherapy (2024-06 to 2024-11), and currently receiving palliative liposomal doxorubicin plus cisplatin (C1: 2025-02-18 to C5: 2025-06-11). Lung metastases were confirmed on lung biopsy (2024-06-27) with PET/CT and chest CT progression noted by 2025-01-03. She has persistent normocytic macrocytic anemia, intermittent leukopenia, and stable renal and hepatic function. Her current ECOG status is 2, and she remains afebrile with stable vitals. The overall clinical course reflects a stable disease burden with chemotherapy-induced cytopenias as the major limiting factor.
Problem 1. Metastatic endometrial adenocarcinoma (lung metastasis, stage IV)
Problem 2. Chemotherapy-induced cytopenias (anemia and leukopenia)
Problem 3. Renal function monitoring (cisplatin use)
Problem 4. Cardiac function surveillance (not posted)
Problem 5. Chronic comorbidities (HTN, hyperlipidemia, insomnia)
[proactive neutropenia management in reduced-dose chemotherapy]
Currently, paclitaxel and carboplatin are being administered at 80% of the standard dose, but neutropenia is still present.
To mitigate this, administering G-CSF at the appropriate time during treatment may help manage the development of neutropenia and reduce its severity.
2024-10-08 WBC 2.38 x10^3/uL
2024-09-18 WBC 1.52 x10^3/uL
2024-09-08 WBC 2.33 x10^3/uL
2024-08-28 WBC 1.26 x10^3/uL
2024-08-18 WBC 2.39 x10^3/uL
2024-10-08 Neutrophil 63.0 %
2024-09-18 Neutrophil 52.3 %
2024-09-08 Neutrophil 63.9 %
2024-08-28 Neutrophil 42.8 %
2024-08-18 Neutrophil 69.1 %
[optional G-CSF prophylaxis after reduced paclitaxel and carboplatin dose]
Neutropenia was observed after the administration of paclitaxel and carboplatin. The session initiated on 2024-08-19 used 90% of the original dose. Prophylactic G-CSF might be also prepared in advance after the administration.
2024-08-18 WBC 2.39 x10^3/uL *
2024-07-22 WBC 4.25 x10^3/uL
2024-07-09 WBC 1.23 x10^3/uL **
2024-06-26 WBC 3.54 x10^3/uL
2024-08-18 Neutrophil 69.1 %
2024-07-22 Neutrophil 67.3 %
2024-07-09 Neutrophil 9.6 % **
2024-06-26 Neutrophil 72.9 %
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
The patient is a 57-year-old male with metastatic low rectal adenocarcinoma (cT3N2bM1b, stage IVb) with liver and bone involvement, currently receiving mFOLFOX6 + bevacizumab chemotherapy since 2024-07-29. As of 2025-06-12, his overall condition is stable with ECOG PS 1. Laboratory results show mild but stable microcytic anemia, good renal and hepatic function, and no signs of acute infection or inflammation. Imaging (CT 2025-03-01) suggests stable metastases in the liver and bone. He received his most recent chemotherapy on 2025-05-05, and denosumab was administered on 2025-06-12 for bone metastasis prophylaxis. His blood pressure is stable, diabetes appears controlled, and there is ongoing monitoring and supportive care for his multi-morbidity status.
Problem 0. Metastatic rectal adenocarcinoma (liver and bone) (old version, not posted)
Problem 1. Metastatic rectal adenocarcinoma with liver and bone metastases (cT3N2bM1b, stage IVb, RAS/BRAF wild-type, left-sided)
Problem 2. Skeletal metastasis and SRE (skeletal-related event) prevention
Problem 3. Microcytic anemia
Problem 4. Electrolyte imbalance (Hyponatremia) (not posted)
Problem 5. Type 2 diabetes mellitus (on insulin)
Problem 6. GERD and GI symptoms
Problem 7. Psychosocial and psychiatric vulnerability
[Left-sided colorectal cancers] (not posted)
“Left-sided” colorectal cancers (those originating from the splenic flexure, descending colon, sigmoid colon, and rectum) are clinically and molecularly distinct from “right-sided” cancers (cecum, ascending colon, and proximal transverse colon). This distinction matters particularly in metastatic disease, because it directly influences treatment selection and prognosis, especially regarding anti-EGFR therapy.
Key Differences: Left-sided vs Right-sided Colorectal Cancer
Conclusion:
Since the last review on 2025-01-13, the patient has continued bevacizumab + FOLFOX chemotherapy with cycles administered on 2025-01-23 and 2025-02-27. Laboratory trends indicate stable renal and liver function, mild anemia, and normal inflammatory markers, with no immediate concerns of infection or worsening organ function. However, tumor progression risk remains, necessitating ongoing monitoring and treatment reassessment.
Problem 1. Metastatic Rectal Cancer
Problem 2. Bone Metastases and Skeletal Health
Problem 3. Hematologic Trends and Chemotherapy Tolerance
Problem 4. Renal Function and Electrolyte Balance
Problem 5. Inflammatory and Infection Markers
Summary of Key Changes Since 2025-01-13
Immediate Action Plan
The patient is a 56-year-old male with advanced rectal adenocarcinoma (initially stage IIIC, now progressed to stage IVb with liver and bone metastases) and multiple comorbidities, including type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), alcoholic liver disease, and mood disorder. Over the course of treatment, he has undergone neoadjuvant therapy, multiple cycles of FOLFOX with Avastin (bevacizumab) added since 2024-10-30.
Problem 1. Metastatic Rectal Cancer
Problem 2. Hepatic Function
Problem 3. Bone Metastases
Problem 4. Hematological Concerns
Problem 5. Electrolyte and Renal Concerns
Problem 6. Psychosocial and Functional Status
[Targeted Therapy Options]
Overall Recommendations:
[Improved, but Elevated HbA1c: Continued Monitoring Needed]
For this patient with mCRC, the 2024-07-29 RAS/BRAF mutation test results showing no variants in the KRAS/NRAS (ALL-RAS wild-type) and BRAF wild-type mean that the patient is a candidate for EGFR inhibitor therapy (such as cetuximab or panitumumab).
The patient’s HbA1c level has improved but remains higher than the reference range. His current blood glucose readings are also elevated but are considered acceptable. There are no drug-related issues identified.
[exam finding]
2025-06-09 Peripheral Vascular Test - Artery, lower limbs
2025-06-06 Pathology - colorectal polyp
2025-06-06 Pathology - stomach biopsy
2025-06-05 Esophagogastroduodenoscopy, EGD
2025-06-05 Colonoscopy
2025-06-05 Sonography - abdomen
2025-06-03 Pathology - liver biopsy needle/wedge
2025-05-31 CT - abdomen
2025-05-31 ECG
2025-05-31 KUB
2025-05-31 CXR
2025-02-11 Esophagogastroduodenoscopy, EGD
2024-10-04 Esophagogastroduodenoscopy, EGD
2024-10-02 KUB
2024-08-09 Sonography - nephrology
2024-08-09 2D transthoracic echocardiography
2024-08-08 CXR
2024-08-08 05:49 ECG
2024-08-08 CT - abdomen
2024-08-08 CT - brain
2024-08-08 00:06 ECG
2024-07-18 MRA - brain
2024-07-17 CT - chest
[MedRec] (not completed)
[consultation] (not completed)
[exam finding]
[MedRec]
[exam findings]
[MedRec]
2025-06-02 ~ 2025-06-04 POMR General and Gastroenterological Surgery Zhang YaoRen
2025-05-28 SOAP Ophthalmology Shen PeiYu
2025-03-31 ~ 2025-05-05 POMR Orthopedics Li YiCheng
2025-01-06 SOAP General and Gastroenterological Surgery Zhang YaoRen
2025-01-06 SOAP Metabolism and Endocrinology Qiu QuanTai
2024-10-30 ~ 2024-11-13 POMR Orthopedics Luo Jie
2023-01-15 ~ 2023-01-18 POMR Nephrology Guo KeLin
2022-08-12 ~ 2022-08-20 POMR Infectious Disease Qiu ShengKang
2022-05-30 ~ 2022-06-03 POMR Infectious Disease Wu JunSheng
2021-10-12 ~ 2021-10-14 POMR Hemato-Oncology Zhang ShouYi
2020-09-24 ~ 2020-09-30 POMR General and Gastroenterological Surgery Zhang YaoRen
2020-03-02 ~ 2020-03-04 POMR General and Gastroenterological Surgery Zhang YaoRen
2020-02-06 ~ 2020-02-08 POMR General and Gastroenterological Surgery Zhang YaoRen
2019-08-01 ~ 2019-08-04 POMR General and Gastroenterological Surgery Zhang YaoRen
[immunochemotherapy]
[Subjective]
medication administration and caregiver education
cancer status and supportive medication history
[Objective]
current active medications
laboratory findings on 2025-06-11
[Assessment]
drug-food interaction and administration timing
Enhertu-related adverse event monitoring
polypharmacy considerations
[Plan / Recommendation]
optimize antiviral and fasting medication schedule
Enhertu safety monitoring
review GI protective strategy
evaluate CNS and sedation risks
reassess polypharmacy and therapeutic duplication
follow-up
[exam finding]
[MedRec]
[Subjective]
medication counseling
lifestyle and history
[Objective]
lab data on 2025-06-02
cardiology record
[Assessment]
dual antiplatelet therapy adherence importance
hyperuricemia management
[Plan / Recommendation]
reinforce antiplatelet adherence
gout management strategy
optimize lipid management
lifestyle and long-term care
[exam finding]
[MedRec]
[surgical operation]
[immunochemotherapy]
2025-06-09 - cetuximab 500mg/m2 1000mg 2hr + irinotecan 120mg/m2 220mg D5W 250mL 90min + leucovorin 300mg/m2 570mg NS 250mL 2hr + fluorouracil 2000mg/m2 3800mg NS 500mL 46hr (Erbitux + FOLFIRI)
2025-05-22 - cetuximab 500mg/m2 1000mg 2hr
2025-05-08 - cetuximab 500mg/m2 1000mg 2hr
2025-04-24 - cetuximab 500mg/m2 1000mg 2hr
2025-04-10 - cetuximab 500mg/m2 1000mg 2hr
2025-03-27 - cetuximab 500mg/m2 1000mg 2hr
2025-03-13 - cetuximab 500mg/m2 1000mg 2hr
2025-02-18 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 90min + irinotecan 120mg/m2 240mg D5W 250mL 90min (Y-sited Covorin) + leucovorin 400mg/m2 750mg NS 250mL 90min (Y-sited Irino) + fluorouracil 2400mg/m2 4700mg NS 170mL 48hr (infusor)
2025-02-04 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 90min + irinotecan 120mg/m2 240mg D5W 250mL 90min (Y-sited Covorin) + leucovorin 400mg/m2 750mg NS 250mL 90min (Y-sited Irino) + fluorouracil 2400mg/m2 4800mg NS 170mL 48hr (infusor)
2025-01-21 - bevacizumab 5mg/kg 200mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 90min + irinotecan 120mg/m2 240mg D5W 250mL 90min (Y-sited Covorin) + leucovorin 400mg/m2 750mg NS 250mL 90min (Y-sited Irino) + fluorouracil 2400mg/m2 4600mg NS 170mL 48hr (infusor) (Avastin not enough)
2025-01-08 - bevacizumab 5mg/kg 200mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 90min + irinotecan 120mg/m2 240mg D5W 250mL 90min (Y-sited Covorin) + leucovorin 400mg/m2 750mg NS 250mL 90min (Y-sited Irino) + fluorouracil 2400mg/m2 4600mg NS 170mL 48hr (infusor) (Avastin not enough)
2024-12-25 - bevacizumab 5mg/kg 200mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 90min + irinotecan 120mg/m2 240mg D5W 250mL 90min (Y-sited Covorin) + leucovorin 400mg/m2 750mg NS 250mL 90min (Y-sited Irino) + fluorouracil 2400mg/m2 4600mg NS 170mL 48hr (infusor) (Avastin not enough)
2024-12-06 - bevacizumab 5mg/kg 397mg NS 100mL 90min + irinotecan 180mg/m2 350mg D5W 250mL 90min + leucovorin 400mg/m2 778mg NS 250mL 2hr + fluorouracil 2800mg/m2 5446mg NS 1000mL 46hr (Avastin + FOLFIRI)
2024-11-21 - bevacizumab 5mg/kg 358mg NS 100mL 90min + irinotecan 180mg/m2 315mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4910mg NS 1000mL 46hr (Avastin + FOLFIRI)
2024-11-07 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 264mg D5W 250mL 90min + leucovorin 400mg/m2 587mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 1000mL 46hr (Avastin + FOLFIRI)
2024-10-11 - bevacizumab 5mg/kg 275mg NS 100mL 90min + irinotecan 180mg/m2 244mg D5W 250mL 90min + leucovorin 400mg/m2 543mg NS 250mL 2hr + fluorouracil 2800mg/m2 3800mg NS 1000mL 46hr (Avastin + FOLFIRI)
2024-09-20 - bevacizumab 5mg/kg 278mg NS 100mL 90min + irinotecan 180mg/m2 244mg D5W 250mL 90min + leucovorin 400mg/m2 543mg NS 250mL 2hr + fluorouracil 2800mg/m2 3808mg NS 1000mL 46hr (Avastin + FOLFIRI)
2024-08-30 - bevacizumab 5mg/kg 277mg NS 100mL 90min + irinotecan 180mg/m2 244mg D5W 250mL 90min + leucovorin 400mg/m2 543mg NS 250mL 2hr + fluorouracil 2800mg/m2 3806mg NS 1000mL 46hr (Avastin + FOLFIRI)
2024-08-09 - bevacizumab 5mg/kg 273mg NS 100mL 90min + irinotecan 180mg/m2 243mg D5W 250mL 90min + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2800mg/m2 3780mg NS 1000mL 46hr (Avastin + FOLFIRI)
2024-07-19 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4300mg NS 1000mL 46hr (Avastin + FOLFIRI)
2024-06-21 - bevacizumab 5mg/kg 391mg NS 100mL 90min + irinotecan 180mg/m2 346mg D5W 250mL 90min + leucovorin 400mg/m2 770mg NS 250mL 2hr + fluorouracil 2800mg/m2 5395mg NS 1000mL 46hr (Avastin + FOLFIRI)
2024-06-07 - bevacizumab 5mg/kg 388mg NS 100mL 90min + irinotecan 180mg/m2 346mg D5W 250mL 90min + leucovorin 400mg/m2 770mg NS 250mL 2hr + fluorouracil 2800mg/m2 5395mg NS 1000mL 46hr (Avastin + FOLFIRI)
2024-05-24 - bevacizumab 5mg/kg 385mg NS 100mL 90min + irinotecan 180mg/m2 345mg D5W 250mL 90min + leucovorin 400mg/m2 765mg NS 250mL 2hr + fluorouracil 2800mg/m2 5359mg NS 1000mL 46hr (Avastin + FOLFIRI)
2024-05-10 - bevacizumab 5mg/kg 385mg NS 100mL 90min + irinotecan 180mg/m2 345mg D5W 250mL 90min + leucovorin 400mg/m2 765mg NS 250mL 2hr + fluorouracil 2800mg/m2 5359mg NS 1000mL 46hr (Avastin + FOLFIRI)
2024-04-26 - (Avastin + FOLFIRI)
2024-04-11 - (Avastin + FOLFIRI)
2024-03-21 - (Avastin + FOLFIRI)
2024-03-01 - (Avastin + FOLFIRI)
2024-02-15 - (FOLFIRI)
2024-01-24 - (FOLFIRI)
2025-03-13 ~ ongoing - Tafinlar (dabrafenib mesylate 75mg) 2# BIDAC
This is a 62-year-old male with advanced sigmoid colon adenocarcinoma (cT4aN2bM1b, pT3N1bM1b, stage IVb) post-laparoscopic sigmoidectomy (2023-12-14), with progressive liver and nodal metastases despite multiple lines of palliative chemotherapy. He recently transitioned to Erbitux + FOLFIRI (first dose on 2025-06-09) after disease progression under prior Avastin + FOLFIRINOX. Tumor burden is increasing (CEA 1866→2329 ng/mL from 2025-05-22 to 2025-06-05; CT 2025-05-29 showed liver nodules up to 3.0 cm, new 0.9 cm lesion at LLL). Concurrent chronic conditions include type 2 diabetes (HbA1c 7.5–7.7%) and resolved HBV (Anti-HBc+), under antiviral prophylaxis with Baraclude (entecavir). He presents with abdominal distension and constipation; labs show transaminitis, cholestasis, and mild hypoMg. Clinical status is ECOG PS 1, afebrile, hemodynamically stable.
Problem 1. Progressive sigmoid colon adenocarcinoma with liver and nodal metastases
Problem 2. Hepatic dysfunction (transaminitis and cholestasis)
Problem 3. Type 2 diabetes mellitus
Problem 4. Electrolyte disturbances: hypokalemia and hypomagnesemia
Problem 5. Constipation and abdominal distension
[monitoring diarrhea occurrence after chemotherapy dosage adjustment]
Palliative chemotherapy with FOLFIRI was started on 2024-01-24, and Avastin was added on 2024-02-15. This regimen has been in use for approximately six months. Although both irinotecan and fluorouracil can cause diarrhea, the patient has tolerated them well in the past. This raises the question of whether the patient’s condition or physiology has changed, warranting further investigation.
The most recent administration of Avastin + FOLFIRI was on 2024-07-19, with the dosage adjusted to 80% of the previous amount. This is a reasonable measure, and further observation is needed to determine if diarrhea still occurs.
[exam finding]
[MedRec]
[surgical operation]
[lab data]
2025-05-22 HBsAg Nonreactive
2025-05-22 HBsAg Value 0.34 S/CO
2025-05-22 Anti-HBs 2.59 mIU/mL
2025-05-22 Anti-HBc Nonreactive
2025-05-22 Anti-HBc Value 0.23 S/CO
2025-05-22 Anti-HCV Nonreactive
2025-05-22 Anti-HCV Value 0.12 S/CO
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
This is a postoperative patient with advanced right buccal squamous cell carcinoma (pT4aN3b, AJCC IVB per pathology 2025-05-02) who underwent extensive surgery including wide excision, right neck dissection, marginal mandibulectomy, partial maxillectomy, and tracheostomy. Imaging from 2025-05-23 shows persistent cardiomegaly and bilateral pulmonary interstitial changes. Blood tests from 2025-05 to 2025-06 reveal ongoing anemia, intermittent hypokalemia, and improving nutritional markers (albumin trending up). Inflammatory markers (CRP) have gradually improved. The patient is on multiple oral medications including antihypertensives, antidiabetics, antiplatelets, and pain/antispasmodic agents. Blood pressure remains elevated despite treatment. Glucose levels are suboptimally controlled with recent values of 135–147 mg/dL. Audiometry (2025-05-20) shows asymmetric mixed hearing loss, more severe on the right.
Problem 1. Advanced Buccal Cancer (pT4aN3b, postoperative)
Problem 2. Normocytic Anemia with Iron Deficiency
Problem 3. Chronic Inflammation (elevated CRP)
Problem 4. Hypokalemia (intermittent, moderate)
Problem 5. Suboptimal Blood Pressure Control
Problem 6. Suboptimally Controlled Type 2 Diabetes Mellitus
Problem 7. Hearing Loss (asymmetric)
[lab data]
2025-04-28 HBV-DNA-PCR Target Not Detected IU/mL
2025-04-01 HBsAg (NM) Negative
2025-04-01 HBsAg Value (NM) 0.382
2025-04-01 Anti-HBc (NM) Positive
2025-04-01 Anti-HBc Value (NM) 0.009
2025-04-01 Anti-HBs (NM) Negative
2025-04-01 Anti-HBs value (NM) <2.0 mIU/mL
2025-04-01 Anti-HCV (NM) Negative
2025-04-01 Anti-HCV Value (NM) 0.033
[exam finding]
[MedRec]
[surigcal operation]
[radiotherapy]
[chemotherapy]
This is a 71-year-old male with no significant comorbidities, recently diagnosed with stage IIIB low rectal adenocarcinoma (cT3N2aM0), EGFR(+), MMR-proficient (MLH1/PMS2/MSH2/MSH6 positive), complicated by obstruction, status post transverse loop colostomy on 2025-04-10. He is undergoing total neoadjuvant therapy (TNT), including chemoradiotherapy with bolus 5-FU and pelvic RT. As of 2025-06-09, he has completed two cycles of CCRT and is clinically stable, with preserved organ function, mild anemia, and no major toxicities. Concurrent HBV infection (anti-HBc positive, HBsAg negative, undetectable HBV DNA) is under prophylaxis with Vemlidy (tenofovir alafenamide). Vital signs remain stable, and no febrile or hemodynamic complications have emerged.
Problem 1. Rectal adenocarcinoma, stage IIIB (cT3N2aM0), undergoing CCRT
Problem 2. Chronic hepatitis B (anti-HBc+), on antiviral prophylaxis
Problem 3. Anemia
[exam finding]
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
[Broen-C Enteric-coated Tablet (Bromelain 20,000 units & L-Cysteine 20 mg) for Tube Feeding]
Key Points
Summary:
This 64-year-old woman with esophageal squamous cell carcinoma (middle third, cT3N3M0, stage IVA) and synchronous hypopharyngeal squamous cell carcinoma (left pyriform sinus/posterior wall, cT2N0M0, stage II) has completed 20 fractions of concurrent chemoradiotherapy (CCRT) with cisplatin + fluorouracil (2025-04-22 to 2025-04-25, 2025-05-23 to 2025-05-26), totaling 4000cGy to the hypopharynx and 3600cGy to the esophagus. She is experiencing treatment-related mucositis, esophagitis, and hematologic suppression, yet maintains a stable ECOG 1 with minimal weight loss and no systemic disease progression to date (MRI 2025-04-12, PET 2025-03-26, Bone Scan 2025-04-14). HBV remains under control on Vemlidy (tenofovir alafenamide) prophylaxis.
Problem 1. Esophageal squamous cell carcinoma (cT3N3M0, stage IVA)
Problem 2. Hypopharyngeal squamous cell carcinoma (cT2N0M0, stage II)
Problem 3. Bone marrow suppression (anemia, thrombocytopenia, leukopenia)
Problem 4. Nutritional compromise and weight loss risk
Problem 5. Chronic hepatitis B carrier under prophylaxis
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
Patient Evaluation
Problem 1. Large cell neuroendocrine carcinoma with progression
Problem 2. Suspected Rhabdomyolysis
In summary, while the current CK levels do not confirm rhabdomyolysis, the clinical picture and associated laboratory findings raise concern for early or mild muscle injury potentially related to lurbinectedin therapy. Close monitoring and further diagnostic evaluation are warranted to prevent progression and manage potential complications.3
Problem 3. Urine retention
Problem 4. Diarrhea
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
[high HBV DNA PCR level]
The high HBV DNA PCR level of 999,000 IU/mL on 2025-03-22 in this patient strongly suggests active HBV replication, which may represent HBV reactivation, especially in the context of cancer and immunosuppressive therapy.
Interpretation:
Medication Consideration:
Summary:
[exam finding]
2025-05-16 Pap’s Smear
2025-05-02 CT
2025-03-17 KUB
2025-03-13 Sonography - gynecology
2025-03-12 Sonography - nephrology
2025-03-12 2D transthoracic echocardiography
2025-03-10 ECG
2025-02-19 ECG
2025-01-21 Uroflowmetry
2025-01-21 Bladder Sonography
2025-01-20 SONO - abdomen
2025-01-06, 2024-12-30, -12-09 CXR
2024-12-17 CT - chest
2024-11-28 ENT Hearing Test
2024-11-13 SONO - urology
2024-10-29 Pathology - stomach biopsy
2024-10-29 Esophagogastroduodenoscopy, EGD
2024-10-24 SONO - nephrology
2024-09-09, -08-21 CXR
2024-09-09 Pathology - lung transbronchial biopsy
2024-08-29 PET
2024-08-21 CT - abdomen
2024-08-12 Pap’s
2024-05-23 MRI - pelvis
2024-05-08 SONO - urology
2024-01-22 SONO - urology
2024-01-13 ECG
2024-01-13 CT - abdomen
2023-12-14 CT - abdomen
2023-11-13 SONO - urology
2023-11-13 Bladder Sonography
2023-11-13 Uroflowmetry
2023-07-29 SONO - urology
2023-07-29 Bladder Sonography
2023-07-29 Uroflowmetry
2023-06-29 Anoscopy
….-..-..
2023-03-28 Pathology - uterus (with or without SO) neoplastic
2023-03-27 Pathology - colorectal polyp
2023-03-27 Pathology - stomach biopsy
2023-03-24 CT - chest
2023-03-20 MRI - pelvis
2023-03-17 Gynecologic ultrasonography
2023-03-10 Pathology - vaginal biopsy
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
2025-06-05 - paclitaxel 145mg/m2 210mg NS 500mL 3hr + carboplatin AUC 5 300mg NS 250mL 2hr
2025-05-03 - paclitaxel 145mg/m2 210mg NS 500mL 3hr + carboplatin AUC 5 300mg NS 250mL 2hr
2025-04-08 - paclitaxel 145mg/m2 210mg NS 500mL 3hr + carboplatin AUC 5 300mg NS 250mL 2hr
2025-03-05 - paclitaxel 145mg/m2 200mg NS 500mL 3hr + carboplatin AUC 5 250mg NS 250mL 2hr
2025-01-17 - paclitaxel 120mg/m2 180mg NS 500mL 3hr + carboplatin AUC 5 250mg NS 250mL 2hr (paclitaxel + carboplatin. renal dose)
2024-12-19 - paclitaxel 175mg/m2 270mg NS 500mL 3hr + carboplatin AUC 5 350mg NS 250mL 2hr (paclitaxel + carboplatin)
2024-12-16 - Keytruda (pembrolizumab) 200mg NS 190mL 30min
2024-11-01 - Keytruda (pembrolizumab) 200mg NS 190mL 30min
2024-09-24 - Keytruda (pembrolizumab) 200mg NS 190mL 30min
2024-10-08 - Lenvima (lenvatinib 10mg) 1# QD 20D (OPD prescription)
2024-09-24 - Lenvima (lenvatinib 10mg) 1# QD 7D (Discharge prescription)
2023-12-13 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 300mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
2023-11-17 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 300mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
2023-10-03 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 300mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
2023-09-01 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 300mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
2023-08-11 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 300mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
2023-07-17 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 4 300mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
2023-06-20 - carboplatin AUC 2 150mg D5W 2hr (weekly CDDP changed to carboplatin, CCRT)
2023-06-13 - cisplatin 40mg/m2 60mg NS 500mL 2hr (weekly CDDP, CCRT)
2023-06-06 - cisplatin 40mg/m2 60mg NS 500mL 2hr (weekly CDDP, CCRT)
2023-05-30 - cisplatin 40mg/m2 60mg NS 500mL 2hr (weekly CDDP, CCRT)
2023-05-22 - cisplatin 40mg/m2 60mg NS 500mL 2hr (weekly CDDP, CCRT)
2023-05-02 - cisplatin 40mg/m2 60mg NS 500mL 2hr (weekly CDDP, CCRT)
This 70-year-old woman with FIGO stage IIIC endometrial carcinosarcoma is undergoing her 6th cycle of self-paid paclitaxel + carboplatin chemotherapy (initiated 2024-12-19) following progression under pembrolizumab + lenvatinib. Disease is metastatic (lung confirmed, 2024-09-09 biopsy), with persistent complications including stage 4 chronic kidney disease (CKD), normocytic macrocytic anemia, and intermittent UTI with prior Enterococcus faecalis bacteremia (2025-02-19). She remains ECOG 1, afebrile, and hemodynamically stable (BP range 105–134/58–66 mmHg, SpO2 ≥95%) during current admission (2025-06-04), but shows progressive marrow suppression.
Problem 1. Chronic Kidney Disease (Stage 4)
Problem 2. Normocytic, Macrocytic Anemia (Treatment-Related)
Problem 3. Leukopenia and Neutropenia
Problem 4. Liver Enzyme Elevation (Mild)
Problem 5. Hypothyroidism
[Recommendation Regarding Teicoplanin Dosing Adjustment]
Given the patient’s CrCl of 22 mL/min (2025-02-19) and an eGFR of 25.88 mL/min/1.73m², renal impairment is evident. Current dosing of Targocid (teicoplanin) 400 mg IVD QD does not align with Sanford Guide recommendations for CrCl < 30 mL/min, which suggest a maintenance dose of 6–12 mg/kg Q72H.
Recommended Adjustment:
[Key Summary]
This is a 69-year-old woman with a history of metastatic endometrial carcinosarcoma diagnosed in 2023. She underwent staging surgery, adjuvant concurrent chemoradiotherapy (CCRT) with weekly Cisplatin, subsequent chemotherapy (paclitaxel + carboplatin), and immunotherapy (pembrolizumab + lenvatinib).
Complications include bilateral hydronephrosis requiring serial DJ stent placement, progressive renal impairment, anemia, gastrointestinal ulcers, and lung metastasis. She is currently on chemotherapy with renal-adjusted doses of Paclitaxel + Carboplatin.
[Problem Comments]
Problem 1. Renal Impairment
Problem 2. Pulmonary Metastasis
Problem 3. Hematological Abnormalities (not posted)
Problem 4. Gastrointestinal Ulcers (not posted)
Problem 5. Hypertension and Headache (Lenvatinib-Related Toxicity)
The leukopenia observed on 2023-08-24 (WBC 1.5K/uL) was likely a result of the paclitaxel and carboplatin administered on 2023-08-11. Following a 3-day course of G-CSF from 2023-08-24 to 2023-08-26, no further instances of leukopenia have been observed.
A new cycle of the treatment regimen was initiated on 2023-09-01, and prophylactic G-CSF is scheduled for 2023-09-06, 2023-09-07, and 2023-09-08.
2023-08-31 WBC 3.20 x10^3/uL
2023-08-24 WBC 1.50 x10^3/uL
2023-08-08 WBC 5.12 x10^3/uL
2023-07-25 WBC 3.29 x10^3/uL
2023-07-17 WBC 5.76 x10^3/uL
2023-07-12 WBC 4.41 x10^3/uL
2023-07-03 WBC 1.64 x10^3/uL
2023-06-28 WBC 1.69 x10^3/uL
2023-06-19 WBC 2.08 x10^3/uL
2023-06-12 WBC 2.72 x10^3/uL
2023-06-05 WBC 4.78 x10^3/uL
2023-05-30 WBC 3.99 x10^3/uL
2023-05-22 WBC 4.35 x10^3/uL
2023-05-15 WBC 4.67 x10^3/uL
2023-05-12 WBC 4.78 x10^3/uL
2023-05-09 WBC 8.17 x10^3/uL
2023-05-09 WBC 13.14 x10^3/uL
2023-04-19 WBC 5.07 x10^3/uL
2023-04-03 WBC 5.23 x10^3/uL
2023-03-28 WBC 13.97 x10^3/uL
2023-03-23 WBC 7.35 x10^3/uL
2023-03-03 WBC 5.22 x10^3/uL
The Eltroxin (levothyroxine) prescribed by our endocrinologist on 2023-08-01 is currently listed in the active medications without any reconciliation discrepancies identified.
Our endocrinologist wrote a repeat prescription for Eltroxin (levothyroxine) on 2023-08-01 and the drug is included in the formulary with no reconciliation issue identified.
[reconciliation]
The patient was seen by our urologist on 2023-07-12 who prescribed Cero (cefaclor 250mg) 2# TID and Celebrex (celecoxib 200mg) 1# QD for a period of 7 days to treat suspected UTI infection or catheter-related discomfort. These medications are not currently on the active medication list, so it’s advisable to confirm resolution of these symptoms.
[allergy]
[lab data]
2025-06-04 HBsAg Nonreactive
2025-06-04 HBsAg Value 0.37 S/CO
2025-06-04 Anti-HBc Reactive
2025-06-04 Anti-HBc Value 4.91 S/CO
2022-12-13 Anti-HBc Reactive
2022-12-13 Anti-HBc Value 6.08 S/CO
2022-12-13 HBsAg Nonreactive
2022-12-13 HBsAg Value 0.33 S/CO
2022-12-13 Anti-HCV Reactive
2022-12-13 Anti-HCV Value 12.14 S/CO
[exam findings]
[MedRec]
[consultation]
[immunochemotherapy]
Subjective
Objective
Assessment
Plan / Recommendation
This 77-year-old male with stage IV descending and sigmoid colon adenocarcinoma (KRAS/NRAS wild-type) and chronic hepatitis B (anti-HBc positive, currently on Baraclude) continues palliative chemotherapy with FOLFIRI plus Erbitux. As of 2025-06-05, his liver and renal function remain preserved, and his hematologic profile is stable. He reports grade 2 peripheral sensory neuropathy and persistent constipation (G2) likely due to cumulative chemotherapy toxicity. No active infectious complications or severe systemic toxicity observed. Glycemic control is suboptimal post-chemotherapy (glucose range 112–202 mg/dL).
Problem 1. Advanced metastatic colorectal cancer (Erbitux + FOLFIRI regimen)
Problem 2. Peripheral neuropathy (Grade 2, chemotherapy-induced and diabetic-related)
Problem 3. Constipation (G2)
Problem 4. Chronic Hepatitis B (anti-HBc positive)
Problem 5. Type 2 Diabetes Mellitus (T2DM, suboptimal glycemic control)
Problem 6. Hematologic trend: stable mild thrombocytopenia (not posted)
Since the last review on 2025-01-02, the patient has undergone multiple chemotherapy cycles with cetuximab (Erbitux) + FOLFIRI, and laboratory monitoring indicates hematologic recovery but persistent thrombocytopenia. Liver and renal function remain stable, though BUN has increased. Blood glucose levels remain uncontrolled, showing significant postprandial spikes. Imaging findings indicate no recurrence in the colon but persistent metastatic liver disease with portal hypertension. Recent weight loss of 5 kg (from 81 kg on 2024-11-19 to 76 kg on 2025-03-18) suggests a need for further nutritional evaluation. The most pressing concerns include chemotherapy-related cytopenias, glycemic control, liver metastasis monitoring, and weight loss evaluation.
Problem 1. Chemotherapy-related cytopenia
Problem 2. Hyperglycemia (Uncontrolled Diabetes Mellitus)
Problem 3. Liver Metastases & Cirrhosis with Portal Hypertension
Problem 4. Weight Loss (5 kg Loss in 4 Months)
Problem 5. Blood Pressure Variability
Problem 6. Electrolyte & Renal Function Monitoring
Summary of Next Steps
[Patient Summary]
[Problem Comments]
Problem 1: Recurrent Liver Metastases with Suboptimal Treatment Response
Problem 2: Suboptimal Glycemic Control
Problem 3: Hypertension with Cardiovascular Risk
[managing high blood glucose during cancer therapy]
During this hospitalization, the patient has maintained stable vital signs and lab results from 2024-04-24 have been grossly normal. There is no contraindication to proceeding with this session of Erbitux plus FOLFIRI.
However, blood glucose levels have been recorded around 200 mg/dL, which remains elevated despite current medications, Relinide (repaglinide) and Galvus Met (vildagliptin, metformin). If these high glucose levels persist, the introduction of additional antihyperglycemic agents may be necessary.
[reconciliation]
There is no evidence in the lab results on 2024-04-01 to be a contraindication to the administration of chemotherapy.
[Baraclude (entecavir) dosage for reduced kidney function]
Renal function lab results:
2024-03-11 Creatinine 1.52 mg/dL
2024-02-27 Creatinine 1.26 mg/dL
2024-02-15 Creatinine 1.32 mg/dL
2024-01-31 Creatinine 1.03 mg/dL
2024-01-18 Creatinine 1.36 mg/dL
2024-01-10 Creatinine 1.11 mg/dL
2024-03-11 eGFR 47.63 ml/min/1.73m^2
2024-02-27 eGFR 59.14 ml/min/1.73m^2
2024-02-15 eGFR 56.05 ml/min/1.73m^2
2024-01-31 eGFR 74.63 ml/min/1.73m^2
2024-01-18 eGFR 54.15 ml/min/1.73m^2
2024-01-10 eGFR 68.45 ml/min/1.73m^2
On 2024-03-11, a serum creatinine level of 1.52 mg/dL was measured, indicating a slight decline in kidney function. For patients taking Baraclude (entecavir) with a CrCl between 30 and 50 mL/minute, the following dosage adjustments are recommended:
Medications prescribed by other departments are incorporated into the current medication list, and no discrepancies have been identified.
In addition to visiting our hemato-oncology department, the patient also consulted our urologist on 2023-07-07 and our cardiologist on 2023-07-14. The urologist prescribed Urief (silodosin) and the cardiologist prescribed Concor (bisoprolol). These medications were accurately added to the active formulary and no discrepancies were found during reconciliation.
According to the current PharmaCloud database, the patient refiled his prescription at Taipei City Hospital on 2023-06-21 for Algitab Chewable Tablets (alginic acid), Avamys Nasal Spray (fluticasone furoate), and Engene Eye Drops Patron (flavineadenine dinucleotide), all of which are valid for 28 days and are currently still valid. However, these medications are not yet on the patient’s active formulary at our hospital. This could lead to potential medication reconciliation discrepancies. It’s advisable for the primary care team to confirm whether these medications are still needed for the patient’s current clinical condition. If these medications are needed, they should be added to the patient’s active formulary accordingly.
Per the PharmaCloud database, this patient recently had an outpatient visit at Taipei City Hospital on 2023-05-24. He was prescribed Algitab, Broen-C, acetaminophen for oral use, and sulfamethoxazole eye drops for a 28-day duration. Most of these medications are intended to manage GI symptoms. Upon examination of the current medication list, equivalent therapeutic drugs have already been prescribed. Consequently, no issues were identified during the medication reconciliation process.
Based on the serum glucose level range of 288 mg/dL to 230 mg/dL, it appears that the patient’s underlying condition of type 2 DM is not well-controlled despite taking Galvus Met (vildagliptin + metformin) and Relinide (repaglinide). However, since there is no evidence of renal insufficiency (as of 2023-04-10 with Cre at 1.02mg/dL, eGFR at 75.67, and BUN at 21), the addition of Dibose (acarbose 100mg) 0.5# TIDAC is recommended if the high glucose level persists.
The recurrence of cancer has left the patient feeling helpless, and he has been visited by a psychiatrist, a counseling psychologist, and a social worker in early Feb 2023. He is currently still taking alprazolam, but his emotional state is stable.
The patient’s HbA1c has shown a slow decline trend, blood sugar readings were 145 to 164 mg/dL on 2/22 and 2/23, there is still room for improvement.
[exam finding]
[MedRec]
This is a patient (74M) with a history of type 2 diabetes mellitus (T2DM), Parkinson’s disease, and prior benign prostatic hyperplasia (BPH) status post laser TURP (2017-08-04). On 2025-05-23, he developed watery diarrhea and was admitted for evaluation. Excisional biopsy of a left axillary mass on 2025-05-13 revealed lymph node metastatic carcinoma with IHC suggestive of non-hepatocytic, non-RCC, non-pulmonary, non-prostatic, non-colorectal origin. Abdominal CT (2025-06-02) revealed no recurrence in post-LAR colon site, and a stable S4 hepatic hemangioma. Labs show preserved organ function. HbA1c remains mildly elevated (7.5% on 2025-05-23). The patient remains afebrile, hemodynamically stable, with normal inflammatory markers and electrolytes.
Problem 1. Metastatic Carcinoma of Unknown Primary (CUP)
Problem 2. Type 2 Diabetes Mellitus
Problem 3. Gastrointestinal Symptom: Watery Diarrhea (not posted)
Problem 4. Chronic Kidney Disease and Volume Status (not posted)
[lab data]
2025-06-03 HBsAg (NM) Negative
2025-06-03 HBsAg Value (NM) 0.385
2025-06-03 Anti-Hbe (NM) Negative
2025-06-03 Anti-Hbe Value (NM) 1.130
2025-06-03 Anti-HBs (NM) Positive
2025-06-03 Anti-HBs value (NM) 53.300 mIU/mL
2025-06-03 Anti-HBc (NM) Positive
2025-06-03 Anti-HBc Value (NM) 0.009
2025-06-03 Anti-HCV (NM) Negative
2025-06-03 Anti-HCV Value (NM) 0.034
[exam finding]
[MedRec]
[surgical operation]
[chemotherapy]
[Subjective]
FOLFOX-related side effect education
Hepatitis B history and antiviral consideration
[Objective]
FOLFOX chemotherapy course 1 administered 2025-05-29
HBV serology (2025-06-03)
Renal function adequate (2025-05-29)
[Assessment]
FOLFOX-related adverse effect monitoring
Chronic hepatitis B (resolved) with risk of chemotherapy-induced reactivation
[Plan / Recommendation]
Supportive care for FOLFOX
HBV reactivation risk mitigation
recommend HBV DNA quantitative testing at next clinic visit if not yet done
if viral load is detectable or patient becomes immunosuppressed, suggest initiating antiviral prophylaxis
document HBV risk and flag for doctor’s review before cycle 2 (scheduled 2025-06-12)
Patient evaluation
Problem 1. Stage IIIC colon adenocarcinoma, post hemicolectomy, adjuvant mFOLFOX6 initiated
Problem 2. Possible early metastatic or indeterminate lesions (lung, renal nodules on CT)
Problem 3. Postoperative renal function trend
Problem 4. Cardiovascular history (CAD with stent, HTN, no angina)
Problem 5. Hepatitis B serology and reactivation risk
[lab data]
2025-05-06 Anti-HBc Reactive
2025-05-06 Anti-HBc-Value 6.17 S/CO
2025-05-06 Anti-HBs 1.20 mIU/mL
2025-05-06 HBsAg Reactive
2025-05-06 HBsAg Value 3844.50 S/CO
2025-05-06 Anti-HCV Nonreactive
2025-05-06 Anti-HCV Value 0.09 S/CO
[exam finding]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
[Subjective]
tube feeding tolerance and post-treatment condition
discharge prescription and symptom management
[Objective]
antiviral prophylaxis and hepatic monitoring
tolerance to enteral feeding and supportive care
chemotherapy and recent adverse effect profile
[Assessment]
HBV reactivation prophylaxis
nutrition and drug delivery via jejunostomy
adverse drug reaction and symptom burden
[Plan / Recommendation]
antiviral monitoring
nutrition and administration support
symptom monitoring and supportive care
clinical pharmacist follow-up
This is a 60-year-old man diagnosed with stage III (cT3N2M0, AJCC 8th) moderately differentiated squamous cell carcinoma of the lower third of the esophagus (biopsy 2025-04-30; PET 2025-05-07; EUS 2025-05-08). He presented with progressive dysphagia and weight loss since NSAID use for shoulder trauma. The tumor obstructed the lumen and necessitated feeding jejunostomy and Port-A placement (2025-05-14). He underwent concurrent chemoradiotherapy with cisplatin + 5-FU (PF4; 2025-05-20 to 2025-05-23) and RT (2700 cGy/15 fractions to 2025-06-02), with generally well-tolerated effects. He has chronic hepatitis B (HBsAg 3844.5 S/CO, Anti-HBc reactive on 2025-05-06), managed with Vemlidy (tenofovir alafenamide). His recent labs show stable renal and hepatic function, mild normocytic anemia (HGB 10.8 g/dL on 2025-05-26), and transient leukopenia post-chemotherapy (WBC 3.21 x10^3/uL on 2025-05-26).
Problem 1. Esophageal squamous cell carcinoma, stage III (cT3N2M0)
Problem 2. Chronic hepatitis B with high HBsAg titer
Problem 3. Post-chemotherapy myelosuppression
Problem 4. Nutritional compromise and cachexia
Problem 5. Electrolyte and renal function status
[lab data]
2025-05-10 HBsAg Nonreactive
2025-05-10 HBsAg Value 0.27 S/CO
2025-05-10 Anti-HBc Reactive
2025-05-10 Anti-HBc Value 5.18 S/CO
2025-05-10 Anti-HCV Nonreactive
2025-05-10 Anti-HCV Value 0.11 S/CO
[exam finding]
[MedRec]
[immunochemotherapy]
The 77-year-old woman with urothelial cell carcinoma of the right renal pelvis, sarcomatoid variant, presented with multiple lung metastases (MRI 2025-05-14), clinical stage cT3N2M1 (Stage IV). She has a background of Sjogren syndrome, CKD stage 3, and hyperuricemia. After the initial cycle of immunochemotherapy (pembrolizumab + enfortumab vedotin on 2025-05-14 and 2025-05-22), she now presents on 2025-06-03–06-04 with fatigue, anorexia, and minor weight loss, but no signs of infection or progression-related dyspnea.
Current status:
Problem 1. Metastatic urothelial carcinoma (renal pelvis, sarcomatoid phenotype, cT3N2M1, stage IV)
Problem 2. Fatigue and anorexia
Problem 3. Renal function impairment (CKD stage 3)
Problem 4. Dermatologic toxicity
[exam finding]
[MedRec]
2025-01-17 ~ 2025-01-24 POMR Hemato-Oncology Lin YiTing
2025-01-09 SOAP Cardiology Zhou XingHui
2024-12-27 ~ 2025-01-04 POMR Hemato-Oncology Lin YiTing
2024-11-24 ~ 2024-11-26 POMR Cardiology Zhou XingHui
2024-07-01 ~ 2024-07-03 POMR Hemato-Oncology Gao WeiYao
2024-05-23 ~ 2024-06-09 POMR Obstetrics and Gynecology Shao ZhiXuan
2023-10-01 ~ 2023-10-04 POMR Cardiology Zhou XingHui
2023-07-18 ~ 2023-07-22 POMR Infectious Disease
2023-05-04 ~ 2023-05-20 POMR Infectious Disease
2023-02-05 ~ 2023-02-10 POMR Cardiology Zhou XingHui
2022-05-16 ~ 2022-05-25 POMR Nephrology Guo KeLin
2021-12-29 ~ 2022-01-19 POMR Nephrology Guo KeLin
2021-11-10 ~ 2021-11-23 POMR Nephrology Guo KeLin
[consultation]
2025-05-06 Nephrology
2025-04-16 Nephrology
2025-03-17 Nephrology
2025-02-24 Nephrology
2025-02-05 Nephrology
….-..-..
[surgical operation]
[chemotherapy]
This is a 56-year-old woman with:
Problem 1. Volume overload with bilateral pleural effusions and heart failure
Problem 2. Anemia (multifactorial, ESRD + inflammation + possible GI loss)
Problem 3. Advanced right ovarian cancer with peritoneal carcinomatosis (FIGO IV, BRCA-wildtype)
Problem 4. Electrolyte imbalance and uremia in ESRD (not posted)
Problem 5. Diabetes mellitus with adequate short-term glycemic control
[Key Insights / Summary]
The patient is a 56-year-old woman with advanced right ovarian high-grade serous carcinoma with peritoneal carcinomatosis (pT3cN0M1, FIGO stage IV), status post debulking surgery on 2024-05-31, receiving palliative chemotherapy with paclitaxel/carboplatin (C1-C4 completed). She also has significant comorbidities including coronary artery disease (post-PTCA for middle LCX in 2023 with persistent RCA stenosis), hypertensive heart disease, type 2 diabetes mellitus, end-stage renal disease on hemodialysis (QW135), hypothyroidism, and chronic anemia.
She was admitted on 2025-05-06 for intermittent chest tightness and abdominal bloating with bilateral pleural effusions (transudative) and worsening anemia. The current course is complicated by chronic dyspnea, moderate hypoxia (SpO₂ 95-100%), and chronic metabolic derangements. The most recent CXR (2025-05-05) showed bilateral pleural effusion and ground glass opacities. Pleural tapping confirmed transudate (pleural TP 3.7 g/dL, LDH 113 U/L) (2025-05-06).
Hematology is notable for persistent anemia (Hgb 7.4 g/dL on 2025-05-06) and chronic renal impairment (Cr 4.11 mg/dL, eGFR 11.97 mL/min/1.73m² on 2025-05-05). Blood gases revealed chronic compensated hypercapnia (PCO₂ 55.6 mmHg, HCO₃ 31.1 mmol/L) (2025-05-06). She remains on extensive supportive medications including “Coralan (ivabradine)”, “Coxine (isosorbide-5-mononitrate)”, “Diovan (valsartan)”, and “Fentanyl Transdermal Patch (fentanyl)” for heart failure and pain control.
[Problem-Oriented Deliberation]
Problem 1. Bilateral pleural effusion with dyspnea and hypoxia
Problem 2. Chronic anemia in ESRD with ongoing chemotherapy
Problem 3. Chronic heart disease with intermittent chest discomfort
Problem 4. End-stage renal disease with metabolic derangements
Problem 5. Constipation and gastrointestinal symptoms
[Patient Summary]
The patient is a 55-year-old woman with a complex medical history including right ovarian high-grade serous carcinoma with peritoneal carcinomatosis (pT3cN0M1, FIGO stage IV, s/p debulking surgery on 2024-05-31), ESRD on hemodialysis, hypertensive heart disease, type 2 diabetes mellitus, CAD (post-PTCA and stenting for middle LCX in 2023, with two-vessel disease diagnosed in 2024), and chronic anemia.
She was admitted on 2025-02-24 due to dyspnea, chest discomfort, and bilateral lower extremity edema for two days.
She is receiving Sintrix (ceftriaxone) 2000 mg IV daily for suspected left lung pneumonia and oxygen therapy. Chest ultrasound is scheduled for 2025-02-26 for possible drainage evaluation.
Overall Priorities
[Problems]
Problem 1. Left pleural effusion with suspected pneumonia
Problem 2. Volume overload due to ESRD on hemodialysis (QW135)
Problem 3. Worsening anemia with thrombocytosis
Problem 4. Advanced right ovarian carcinoma with peritoneal carcinomatosis
Key Clinical Issues:
Management Recommendations:
[Patient-Specific Oncology Management Recommendations]
Diagnosis and Staging
Histologic Type: High-grade serous carcinoma of the ovary with peritoneal carcinomatosis, AJCC 8th Edition Stage IIIC (pT3cN0M0).
Surgical Outcome:
Post-Surgical Considerations
[Adjuvant Therapy Options]
Chemotherapy
Maintenance Therapy
Surveillance and Monitoring
Additional Considerations
[exam finding]
[MedRec]
[immunochemotherapy]
This is an 82-year-old male with relapsed IgG-type multiple myeloma, ISS stage II, status post autologous PBSCT on 2015-01-14, with prior treatment history including thalidomide, bortezomib, daratumumab-based immunochemotherapy (DRd 2022-02 to 2023-01), and continued oral agents (lenalidomide until 2023-02, thalidomide until 2024-10). He also received bone protection with Xgeva (denosumab 120mg Q1M) until 2022-07, later replaced by Prolia (denosumab 60mg SC) from 2023-09.
Recent labs show progressively rising IgG (6230 mg/dL on 2025-05-16 → 728.98 mg/L FKLC on 2024-12-31 with κ/λ ratio >100), persistent anemia (Hb 7.6 g/dL on 2025-06-02), hypoalbuminemia, hyponatremia, and low-normal calcium. Functional status declined (ECOG PS 4 on 2025-06-03), with tube dependency and chronic comorbidities including COPD, GERD, insomnia, and benign prostatic hyperplasia.
The patient was admitted on 2025-06-02 for further evaluation and chemotherapy preparation. Imaging confirms advanced spinal involvement (multiple vertebral compression fractures including L1, T11, L2 with spondylosis), and chronic pulmonary and cardiac structural changes. Current concerns center on disease progression, symptomatic anemia, electrolyte imbalance, and performance status affecting treatment feasibility.
Problem 1. Relapsed multiple myeloma (IgG type, ISS II)
Problem 2. Anemia
Problem 3. Hyponatremia and borderline hypokalemia
Problem 4. Poor performance status and frailty (not posted)
Problem 5. COPD and chronic pulmonary changes (not posted)
[A few additional integrative and anticipatory comments may help guide further management]
Consideration:
Implication:
Consideration:
Implication:
[assessing thalidomide risks and managing complications in myeloma]
Based on the updated lab results for this patient with multiple myeloma (post-autoPBSCT in 2015 and currently on thalidomide):
General Management:
[Multifaceted Approach to Optimizing Care for the Multiple Myeloma Patient]
Based on the updated laboratory results and the clinical background of this patient with multiple myeloma who underwent autoPBSCT in 2015 and is recently managed with thalidomide, here are the findings, concerns, and management suggestions:
Overall Management Thought:
[exam finding]
[MedRec]
[consultation]
[immunochemotherapy]
This is a 71-year-old woman with stage IVa distal descending colon adenocarcinoma (cT4bN2aM1a) harboring MLH1 loss (Pathology 2025-01-24) and BRAF V600E mutation (2025-02-11), with multiple liver metastases. She has been receiving biweekly Avastin (bevacizumab) + FOLFIRI chemotherapy since 2025-02-14. As of 2025-06-03 (Cycle 4 Day 15), she remains clinically stable, with tolerable side effects. Recent CT (2025-05-15) shows marked regression of primary colon cancer and stable liver metastases, suggesting partial treatment response.
She has normotensive heart disease without heart failure, no evident signs of chemotherapy-induced organ dysfunction, but persistent anemia (Hb 9.7 g/dL on 2025-06-02) and chemotherapy-induced nausea (G2), appetite loss (G2), fatigue (G1), sensory neuropathy (G1).
Problem 1. Metastatic colorectal adenocarcinoma (cT4bN2aM1a, stage IVa)
Problem 2. Chemotherapy-induced gastrointestinal toxicity (nausea G2, appetite loss G2, constipation G1)
Problem 3. Anemia (Grade 2) (not posted)
Problem 4. Chemotherapy-related fatigue and sensory neuropathy
Problem 5. Hypertension (well-controlled) (not posted)
Patient Review
Problem 1: Metastatic Colon Cancer – Response to Chemotherapy
Problem 2: Chemotherapy-Induced Nausea and Vomiting (CINV) and Headache
Problem 3: Upper Gastrointestinal Bleeding Risk (stool OB 3+) (below not posted)
Problem 4: Hypertensive Heart Disease & Cardiac Function Monitoring
Final Summary & Next Steps
[exam finding]
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
[note]
A phase II randomized study of gemcitabine and nab-paclitaxel in combination with S- 1/LV (GASL) or oxaliplatin (GAP) as first-line treatment for metastatic pancreatic cancer — https://www.annalsofoncology.org/article/S0923-7534(24)03110-7/fulltext
This is a 62-year-old man with biopsy-proven ductal adenocarcinoma of the pancreatic tail, moderately differentiated, with invasion of adjacent structures (stomach, spleen, adrenal, kidney, vessels) and metastases to liver, lung, and lymph nodes, clinical stage T4N2M1, stage IV. He presents with persistent abdominal pain, cachexia, and hyperbilirubinemia, and has received first-cycle GASL chemotherapy (Gemcitabine, Abraxane, TS-1, and Leucovorin) between 2025-05-09 and 2025-05-29. He underwent ascites drainage (1500 mL, bloody) on 2025-05-19. His course is complicated by leukocytosis, refractory anemia, and liver dysfunction. As of 2025-06-02, he is afebrile and hemodynamically stable with SpO2 98–99%, and on supportive care including TPN, analgesics, and antibiotics (ceftazidime).
Problem 1. Pancreatic cancer with liver and lung metastases (T4N2M1, Stage IV)
Problem 2. Liver dysfunction and hyperbilirubinemia
Problem 3. Ascites and cachexia
Problem 4. Leukocytosis with possible infection
Problem 5. Refractory anemia (not posted)
[lab data]
2025-02-20 HBsAg Nonreactive
2025-02-20 HBsAg Value 0.30 S/CO
2025-02-20 Anti-HCV Nonreactive
2025-02-20 Anti-HCV Value 0.25 S/CO
2025-02-20 Anti-HBc Nonreactive
2025-02-20 Anti-HBc Value 0.15 S/CO
2025-02-20 Anti-HBs 19.04 mIU/mL
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[immunochemotherapy]
This is a 49-year-old male with dual malignancies: hypopharyngeal cancer (cT4aN0M0) and esophageal squamous cell carcinoma (cT3N2M0, stage IIIB). He completed definitive concurrent chemoradiotherapy (CCRT) with cisplatin, 5-fluorouracil, and self-paid Nivolumab on 2025-04-30. Post-treatment imaging (MRI 2025-05-15 and PET 2025-05-16) showed marked reduction of esophageal tumor burden and nodal uptake, but mildly increased FDG activity in the lower hypopharynx and inlet area with borderline neck LAPs. He was admitted on 2025-05-21 with fever, cough, and diarrhea, raising suspicion for post-CCRT infection. Soonmelt (amoxicillin/clavulanate) was started, and laparoscopic feeding jejunostomy was performed on 2025-05-26 due to progressive dysphagia and nutritional concerns. His nutrition shifted to pump feeding with gradual calorie escalation. Latest endoscopy (EGD 2025-05-29) noted partial regression of esophageal lesions, persistent inlet abnormality, and heterotopic gastric mucosa.
Problem 1. Esophageal squamous cell carcinoma, cT3N2M0, stage IIIB
Problem 2. Hypopharyngeal cancer, post-cricoid region, cT4aN0M0
Problem 3. Nutritional compromise and dysphagia
Problem 4. Infection (suspected bronchopneumonia and acute gastroenteritis)
Problem 5. Hematological suppression and anemia
[OxyContin tube feeding]
Recommendation:
Rationale:
Alternative:
Administration Instructions:
Summary
| Oxycodone Formulation | Tube Administration Allowed? | Notes |
|---|---|---|
| OxyContin (extended-release) | NO | Crushing/dissolving is unsafe. Do not use via tube |
| OxyNorm 5 mg (immediate-release) | YES | Capsule can be opened; contents suitable for tube use. |
Recommendation Summary:
This is a patient with a known history of diabetes mellitus (DM), leukemia (likely acute based on blast percentage), and Sicca syndrome, presenting with fever and leukocytosis. Emergency room evaluation on 2025-06-01 documented acute ill-looking appearance, high-grade fever (up to 38.8°C), tachycardia, and elevated respiratory rate. Laboratory findings indicate acute leukemia with hyperleukocytosis (WBC 17.97→12.9 x10^3/uL), high blast count (38.0%→46.5%), anemia (Hb 10.8→9.2 g/dL), and thrombocytopenia (PLT 27→52 x10^3/uL). The patient also has hypokalemia (K 2.9→3.0 mmol/L), elevated CRP (15.2 mg/dL on 2025-06-01), and microscopic hematuria and pyuria on urinalysis.
Initial impression in ER was unspecified fever. Current issues include:
Problem 1. Acute Leukemia with Hyperleukocytosis
Problem 2. Fever with Suspected Infection
Problem 3. Thrombocytopenia and Bleeding Risk
Problem 4. Hypokalemia
Problem 5. Hyperglycemia
[lab data]
2025-05-08 PIVKA-II 46879.58 mAU/mL
2025-05-07 HBsAg Reactive
2025-05-07 HBsAg (Value) 4020.07 S/CO
2025-05-07 Anti-HCV Nonreactive
2025-05-07 Anti-HCV Value 0.11 S/CO
2025-05-07 Anti-HBc Reactive
2025-05-07 Anti-HBc Value 6.38 S/CO
2025-05-07 Anti-HBs 0.28 mIU/mL
2025-05-07 Anti-HBc IgM Nonreactive
2025-05-07 Anti-HBc IgM Value 0.10 S/CO
2025-05-07 HBeAg Nonreactive
2025-05-07 HBeAg Value 0.383 S/CO
2025-05-07 HBV DNA-PCR (quan) 1080 IU/mL
2025-05-06 C3 220.7 mg/dL
2025-05-05 Ferritin (NM) 661.84 ng/ml
[exam finding]
[MedRec]
[immunotherapy]
This 54-year-old man with chronic HBV infection, liver cirrhosis (Child-Pugh A), and hepatocellular carcinoma (HCC) cT4N0M0, stage IIIB post-TAE (2025-04-23), presented on 2025-05-28 with acute chest tightness, dizziness, and was diagnosed with acute pancreatitis on CT (2025-05-28). Liver imaging consistently shows bilobar HCCs, left lobe portal vein encasement, and suspected tumor necrosis (MRI 2025-05-02; CT 2025-05-28). He has no evidence of metastatic disease (bone scan 2025-04-25). Labs suggest hepatic dysfunction with AST/ALT elevation, preserved synthetic function (albumin 3.8 g/dL, INR 1.00), and a transiently elevated D-dimer. Echocardiogram showed preserved LVEF (65.5%) with moderate to severe MR. He is receiving pain control with fentanyl patch, morphine, and tramadol, along with IO immunotherapy (Durvalumab 1500mg on 2025-05-06). No infection/sepsis signs as CRP and procalcitonin remain low. Current concerns include pancreatitis, HCC progression, hemodynamic fluctuations, and pain control.
Problem 1. Acute Pancreatitis
Problem 2. Advanced Hepatocellular Carcinoma (Stage IIIB)
Problem 3. Liver Function and Cirrhosis (Child-Pugh A)
Problem 4. Pain Management and Opioid Use
Problem 5. Hemodynamic Status and Cardiac Function
[Durvalumab and Acute Pancreatitis: An Uncommon Link]
Acute pancreatitis is a recognized but rare immune-related adverse event (irAE) associated with Durvalumab, an anti-PD-L1 immune checkpoint inhibitor. Although uncommon, cases of immune-mediated pancreatitis have been reported across checkpoint inhibitors (PD-1, PD-L1, CTLA-4), including Durvalumab and combination therapies (e.g., with Tremelimumab) (Ref).
Evaluation in this Case:
Supporting Evidence:
Conclusion:
Next Steps:
References:
[lab data]
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
[note]
Comprehensive Evidence-Based Protocol for Platinum Agents and Hemodialysis - 20250619 - perplexity.ai
Cisplatin Administration
Carboplatin Administration
Oxaliplatin Administration
Integrated Comparison of Protocols
| Parameter | Cisplatin | Carboplatin | Oxaliplatin |
|---|---|---|---|
| HD Timing | ≤3h post-infusion | 16-20h post-infusion | 1-2h post-infusion |
| Dose Reduction | 50-75% | AUC×25 (GFR=0) | 50% |
| Dialyzability | Low (unbound fraction) | High (>50%) | Moderate (50-80%) |
| Key Evidence | 34 | 56 | [3][8]2 |
Critical Implementation Principles
Evidence Hierarchy
1 https://www.sciencedirect.com/science/article/pii/S0923753419394888 2 https://pmc.ncbi.nlm.nih.gov/articles/PMC5703391/ 3 https://clinmedjournals.org/articles/ijor/international-journal-of-oncology-research-ijor-2-017.php 4 https://www.spandidos-publications.com/10.3892/br.2016.714/download 5 https://pmc.ncbi.nlm.nih.gov/articles/PMC10337679/ 6 https://pmc.ncbi.nlm.nih.gov/articles/PMC4321781/ 7 https://www.stonybrookmedicine.edu/sites/default/files/renal-impairment-dosage-adjustment-for-cytotoxics.pdf [8] https://pmc.ncbi.nlm.nih.gov/articles/PMC5844381/ [9] https://pmc.ncbi.nlm.nih.gov/articles/PMC8753493/ [10] https://www.frontiersin.org/journals/pharmacology/articles/10.3389/fphar.2019.01485/pdf [11] https://www.neuroquantology.com/open-access/Comparative+Evaluation+of+Renal+Parameters+in+Patients+Treated+with+Cisplatin%252C+Carboplatin%252C+and+Oxaliplatin_14673/?download=true [12] https://www.uhs.nhs.uk/Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/Uterine-cancer/Endometrial-Carboplatin-Cisplatin-Paclitaxel-RT-21day.pdf [13] https://pcm.amegroups.org/article/view/8174/html [14] https://journals.lww.com/anti-cancerdrugs/Fulltext/2015/08000/Administration_of_chemotherapy_in_patients_on.11.aspx?generateEpub=Article%7Canti-cancerdrugs%3A2015%3A08000%3A00011%7C10.1097%2Fcad.0000000000000243%7C [15] https://www.mdpi.com/1422-0067/21/18/6928 [16] https://www.clinicalkey.com
Enhanced Evidence-Based Summary: Timing of Platinum-Based Chemotherapy and Hemodialysis - 20250619 - chatgpt.com
Cisplatin
Carboplatin
Oxaliplatin
Summary Comparison
| Agent | HD Timing | Dose Adjustment | Evidence Level |
|---|---|---|---|
| Cisplatin | ≤3 hr post-infusion | 25–50% standard dose | Moderate: PK studies, clinical cases 6 |
| Carboplatin | 12–20 hr post-infusion | Calvert (AUC×25 mg) | Strong: PK studies, AUC targets |
| Oxaliplatin | 1–2 hr post-infusion | 50% dose | Emerging: Limited case reports |
Key Clinical Guidelines
Administering hemodialysis (HD) immediately after cisplatin (CDDP) infusion - 20250619 - plerplexicy.ai
Administering hemodialysis (HD) immediately after cisplatin (CDDP) infusion does not necessarily reduce its effectiveness when accompanied by appropriate dosing adjustments and timing protocols. Below is an evidence-based analysis:
Key Pharmacokinetic Mechanism
Clinical Evidence from Studies
Balancing Efficacy and Safety
| Factor | Impact on Efficacy | Clinical Recommendation |
|---|---|---|
| HD Timing | Early HD reduces free cisplatin but spares bound drug | Initiate HD ≤3h post-infusion |
| Dose Adjustment | Lower doses (25–50% reduction) maintain efficacy | Use 25–50 mg/m² for safety |
| Protein Binding | Bound fraction remains active post-HD | No efficacy loss if binding occurs |
Conclusion
Immediate HD after cisplatin administration does not diminish effectiveness when:
1 https://pubmed.ncbi.nlm.nih.gov/18191389/ 2 https://www.dovepress.com/systemic-treatment-for-gynecological-cancer-patients-undergoing-hemodi-peer-reviewed-fulltext-article-OTT 3 https://pmc.ncbi.nlm.nih.gov/articles/PMC6505661/ 4 https://www.nature.com/articles/6600687 5 https://ecancer.org/es/journal/article/1397-successful-treatment-of-a-patient-with-renal-failure-treated-with-haemodialysis-and-advanced-ovarian-germ-cell-tumour-using-modified-cisplatin-based-chemotherapy-duplet/pdf 6 https://pmc.ncbi.nlm.nih.gov/articles/PMC2376779/ 7 https://journals.lww.com/anti-cancerdrugs/Fulltext/2020/10000/Full_dose_cisplatin_chemotherapy_combined_with.14.aspx?generateEpub=Article%7Canti-cancerdrugs%3A2020%3A10000%3A00014%7C10.1097%2Fcad.0000000000000911%7C [8] https://www.sciencedirect.com/science/article/pii/S0923753419394888 [9] https://www.ncbi.nlm.nih.gov/books/NBK547695/ [10] https://www.frontiersin.org/journals/nephrology/articles/10.3389/fneph.2024.1436896/full
Does HD immediately after cisplatin reduce its effectiveness? - 2025-06-19 - chatgpt.com
| Timing & Dose | Free Platinum Removed | Efficacy Impact | Notes |
|---|---|---|---|
| HD ≤3 h post-infusion | Yes (unbound only) | No significant reduction | Maintains protein-bound active drug |
| Reduced dose (25–50%) | Yes | Effective in small studies | Supports tolerability without compromise |
This is a 48-year-old male with esophageal squamous cell carcinoma (M/3, initially cT3N2M0 stage IIIB), who underwent definitive concurrent chemoradiotherapy (PF regimen) starting on 2022-11-02 followed by three-dimensional video-assisted thoracoscopic esophagectomy and gastric tube reconstruction on 2023-03-27. Despite initial surgical remission (ypT3N1M0), disease progression with bilateral renal and hepatic metastases has occurred. Biopsies on 2024-08-20 and 2024-08-21 confirmed metastatic squamous cell carcinoma in both kidneys. Recent imaging (CT 2025-04-01, CXR 2025-05-28) shows stable hepatic/renal tumors and new consolidation over the right upper lung compatible with pneumonia.
Problem 1. Pneumonia with new right upper lobe consolidation
Problem 2. Metastatic esophageal squamous cell carcinoma with bilateral renal and hepatic metastases
Problem 3. Anemia in setting of malignancy and ESRD
Problem 4. Electrolyte and renal disturbances in ESRD with tumor involvement
[nivolumab added to triplet chemotherapy with upward SCC trend]
PD-L1 tumor cell (TC) staining shows 7% expression (between 5% and 10%). Nivolumab was initiated on 2024-10-01 in combination with triplet chemotherapy (docetaxel, cisplatin, fluorouracil).
The tumor marker SCC has been trending upward steadily since 2023Q3. As nivolumab has just been added, continued follow-up is recommended to monitor treatment efficacy. No medication issues have been identified.
[exam findings]
[MedRec]
2025-02-16 ~ 2025-02-27 POMR Hemato-Oncology He JingLiang
2025-01-07 ~ 2025-01-17 POMR Orthopedics Zhu ChungHua
2023-11-21 ~ 2023-12-08 POMR Hemato-Oncology He JingLiang
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
[Valcyte FC (valganciclovir 450mg/tab) tube feeding]
Valcyte F.C. (valganciclovir film-coated tablets) should not be crushed or ground due to hazardous exposure risks and potential alteration of drug delivery. For patients requiring tube feeding, the preferred and safest approach is to use the commercially available oral solution of valganciclovir, which is specifically designed for this purpose2.
However, if the oral solution is unavailable and administration via tube is absolutely necessary, a method known as the “simple suspension method” can be considered, as described in clinical research and practice guidelines4. This method should only be performed by trained healthcare professionals with appropriate precautions due to the drug’s hazardous nature.
How to Administer Valcyte via Tube Feeding (if oral solution is unavailable)
Summary Table
| Step | Details |
|---|---|
| Preferred method | Use commercial oral solution |
| If tablets only | Use simple suspension method with cracked tablet, warm water, and strict safety measures |
| Safety | Wear gloves/mask; avoid powder generation; prepare in ventilated area |
| Flushing | Flush tube before and after with 15–30 mL water |
| Feeding | Stop during administration, resume after |
References:
In summary:
Always use the oral solution for tube feeding if available. If not, the
simple suspension method can be used with extreme caution and
appropriate safety measures.
Citations:
1 https://rudiapt.files.wordpress.com/2017/11/handbook-of-drug-administration-via-enteral-feeding-tubes-2015.pdf 2 https://www.medicines.org.uk/emc/product/8177/smpc 3 https://www.scribd.com/doc/98100059/Guidelines-for-the-Adminstration-of-Drugs-via-Enteral-Feeding-Tubes 4 https://pmc.ncbi.nlm.nih.gov/articles/PMC7339454/ 5 https://www.academia.edu/19624539/2012_03_26Handbk_Of_Drug_Admini_Via_Enteral_Feeding_Tubes_1st_Ed_White_And_Bradn 6 https://www.rlandrews.org/pdf_files/handbk_of_enteralfeeding.pdf 7 https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/021304s008,022257s003lbl.pdf [8] https://academic.oup.com/ajhp/article/66/16/1458/5130347 [9] https://assets.hpra.ie/products/Human/30773/caa5aea4-d4b5-4e2a-9dec-19f8b6752e28.pdf [10] https://www.gene.com/download/pdf/valcyte_prescribing.pdf [11] https://www.medicines.org.uk/emc/product/14225/smpc [12] https://ugc.production.linktr.ee/d15c968f-c888-4165-ab95-197f38afbc7b_DRUG-ADMINISTRATION-VIA-NASOGASTRIC-TUBE---FOR-DYPSHAGIA-PATIENTS.pdf [13] https://assets.roche.com/f/173850/x/ad2abcc5b2/valcyte_pm_e.pdf [14] https://www.medsafe.govt.nz/profs/datasheet/v/valganciclovirmylantab.pdf [15] https://outreach.cheo.on.ca/manual/2283-0 [16] https://deepblue.lib.umich.edu/bitstream/handle/2027.42/78598/j.1399-3062.2009.00478.x.pdf
Problem 1. Anemia
Problem 2. Thrombocytopenia
Here is the updated evaluation of the patient as of 2025-05-15, based on all clinical, imaging, laboratory, therapeutic, and vital data accumulated since the last review on 2025-04-25.
Problem 1. Advanced cholangiocarcinoma with liver and bone metastases
Problem 2. Persistent cytopenias post-chemotherapy (leukocytosis rebound)
Problem 3. Hepatobiliary dysfunction (transaminitis, hyperbilirubinemia)
Problem 4. Electrolyte abnormalities: hypercalcemia and hyponatremia
Problem 5. Pain related to bone metastases
Problem 6. Left chest wall skin lesion (post-herpetic)
Problem 1. Pancytopenia
Problem 2. Advanced Cholangiocarcinoma with Liver and Bone Metastases
Problem 3. Postoperative Bone Metastasis and Pathological Fracture
Problem 4. Hepatotoxicity Under Chemotherapy
Problem 5. Nutritional and Functional Status
This is a 50-year-old female with stage IV intrahepatic cholangiocarcinoma (diagnosed 2023-11-22 via liver biopsy), complicated by metastases to the liver, lymph nodes, bone (confirmed by multiple imaging and pathology), and possibly lung, with ongoing multi-line chemotherapy and radiotherapy. The patient is also a chronic hepatitis B carrier and has undergone multiple orthopedic interventions due to pathological fractures. As of 2025-03-24, the key concerns are:
Problem 1. Pancytopenia
Problem 2. Cholangiocarcinoma with Multisite Metastasis
Problem 3. Metastatic Bone Disease with Pathological Fractures
Problem 4. Chronic Hepatitis B
[potential resistance to current regimen noted]
A bone scan on 2024-04-17 indicated progression of metastatic bone disease compared to the previous study on 2023-11-23. This suggests that the disease may be developing resistance to the current regimen of durvalumab, gemcitabine, and cisplatin. Lab results on 2024-06-12 were generally normal, and no medication discrepancies were identified.
[exam finding]
[MedRec]
[consultation]
[immunochemotherapy]
This 65-year-old man with stage IV gastric cancer (T3N3M1, poorly cohesive type) and extensive lymph node and bone metastases has been undergoing biweekly immunochemotherapy with Opdivo (nivolumab) plus FOLFOX since 2025-01-10. As of the current hospitalization (2025-05-26), he is receiving his 10th session. His general condition remains stable with preserved organ function, tolerable chemotherapy-related adverse effects (Grade 1 fatigue, alopecia, mild leukopenia), and no active infection or organ failure. Vital signs are stable; tumor markers (CEA and CA 19-9) show a mild downward trend. Functional and nutritional status are being maintained, though anemia and mild hypocalcemia persist.
Problem 1. Metastatic gastric cancer under immunochemotherapy
Problem 2. Chemotherapy-induced anemia and leukopenia
Problem 3. Electrolyte disturbances: borderline hypocalcemia
Problem 4. Chemotherapy-related adverse effects
Problem 5. Psychosocial concern and supportive care (not posted)
Updated Patient Evaluation
Since the last review on 2025-02-04, the patient has continued nivolumab (240 mg) + FOLFOX immunochemotherapy on 2025-02-17, 2025-03-03, and 2025-03-17. There are notable trends in hematologic, renal, hepatic, and tumor marker parameters. Imaging updates confirm progression of bone metastases, and pathology findings suggest a gingival/oral mucosal ulcer without malignancy. The patient remains hemodynamically stable with manageable organ function, but persistent anemia, leukopenia, and elevated CA-199 require closer evaluation.
Problem 1. Hematologic Suppression (Anemia, Leukopenia, Thrombocytopenia)
Problem 2. Bone Metastases Progression
Problem 3. Gastrointestinal Symptoms (Diarrhea, Gastric Cancer Progression, and CA-199 Elevation) (below not posted)
Problem 4. Oral Mucosal Ulceration
Problem 5. Electrolyte and Liver Function Trends
Conclusion
The patient is a 65-year-old male diagnosed with poorly cohesive gastric carcinoma with multiple bone and lymph node metastases (T3N3M1, stage IV, as of 2025-01-03). His condition is complicated by anemia, cachexia, recurrent diarrhea, electrolyte imbalances, and evidence of parenchymal liver disease. Treatment includes immunochemotherapy (Nivolumab and FOLFOX regimen) and symptomatic management for gastrointestinal and systemic complications. The disease is progressing, as shown by PET, CT, and lab results, with persistent anemia, signs of malnutrition, and extensive metastases.
Problem 1. Anemia
Problem 2. Gastrointestinal Symptoms and Malnutrition
Problem 3. Bone Metastases and Pain
Problem 4. Electrolyte Imbalances (not posted)
Problem 5. Liver and Renal Function (not posted)
[Possibility of Other Cancers - Evaluation]
Objective Evidence
Assessment
Recommendations
[exam finding]
[MedRec]
[surgical operation]
[Subjective]
beta-blocker related complaints
antiplatelet adherence and bleeding monitoring
dose adjustment discussion
[Objective]
cardiac recovery post-CABG
current medications (2025-05-23)
vitals and labs
[Assessment]
bradycardia and beta-blocker intolerance
post-CABG limb swelling
antiplatelet compliance
[Plan / Recommendation]
bradycardia and Concor titration
post-CABG swelling management
DAPT adherence and bleeding risk
clinical monitoring and communication
Patient Summary
Problem 1. Post-CABG Cardiac Function and Ischemia Risk
Problem 2. Pleural Effusion and Interstitial Lung Edema
Problem 3. Anemia and Postoperative Hematologic Status
Problem 4. Electrolyte and Renal Function
Problem 5. Hepatic Enzyme Elevation
[exam finding]
| mory: 2 |
|---|
| ientation: 2 |
Judgment & Problem Solving: 2
Community Affairs: 2
Home & Hobbies: 2
Personal Care: 1
CDR Score: 2
2023-08-24 MRA - brain
| mory: 2 |
|---|
| ientation: 2 |
Judgment & Problem Solving: 2
Community Affairs: 2
Home & Hobbies: 2
Personal Care: 1
CDR Score: 2
2023-08-21 Mini-Mental State Examination, MMSE
2023-08-14 2D transthoracic echocardiography
2023-08-07 CT - abdomen
2022-05-30 CT - abdomen
2018-12-28 Tc-99m MDP bone scan
2018-12-14 CT - abdomen
2018-08-30 Surgical Pathology Level VI
2018-08-29 CT - abdomen
2018-08-28 2D transthoracic echocardiography
2018-08-24 Sigmoidoscopy
| mory: 1 |
|---|
| ientation: 1 |
Judgment & Problem Solving: 1
Community Affairs: 1
Home & Hobbies: 1
Personal Care: 0
CDR Score: 1
2023-08-21 Mini-Mental State Examination, MMSE
2018-08-10 Surgical Pathology Level IV
2018-07-02 2D transthoracic echocardiography
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[immunochemotherapy]
[note]
Cetuximab: Drug information - 2025-05-28 - https://www.uptodate.com/contents/cetuximab-drug-information
This is a 78-year-old woman with a complex oncologic history of:
She presented on 2025-05-26 with oral pain, poor intake, general weakness, and was admitted from the ED. Laboratory and clinical assessments revealed worsening mucositis (Grade 3), neutrophil predominance (82.7%), elevated CRP (12.2 mg/dL), borderline hypocalcemia (Ca 2.19 mmol/L), weight loss (down to 41 kg), but preserved vital signs and kidney/liver function.
Current clinical status is complicated by treatment-induced mucosal toxicity, nutritional decline, systemic inflammation, and potential secondary infection. Radiation and cetuximab toxicity must be critically evaluated and managed.
Problem 1. Severe oral mucositis and malnutrition
Problem 2. Locoregionally advanced recurrent tongue cancer under Bio-RT
Problem 3. Chronic inflammation and possible secondary infection
Problem 4. Electrolyte and renal profile monitoring (not posted)
Problem 5. Frailty and functional decline
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[Subjective]
antiplatelet therapy adherence and bleeding concern
hepatitis B risk during chemotherapy
biliary tree evaluation
[Objective]
antiplatelet use and cardiovascular history
HBV serology (2025-05-12)
biliary imaging and labs
[Assessment]
antiplatelet management
HBV reactivation risk
biliary tract findings
[Plan / Recommendation]
antiplatelet therapy
HBV prophylaxis
biliary tree follow-up
This 70-year-old male has a confirmed diagnosis of moderately differentiated sigmoid colon adenocarcinoma (pT3N1aM0, AJCC stage IIIB) based on resection pathology dated 2025-05-13. He underwent single-incision laparoscopic anterior resection (SILS) on 2025-05-12 with negative resection margins and one of twenty mesocolic lymph nodes positive for metastasis. Notably, the patient also has significant cardiovascular comorbidity: he experienced acute anterior STEMI with triple vessel disease and underwent successful primary PCI with DES for proximal-to-mid LAD on 2025-03-23. He remains on dual antiplatelet therapy and cardiovascular medications. Lab data postoperatively are mostly stable; however, he is seropositive for anti-HBc, indicating prior HBV exposure. Planning for adjuvant chemotherapy (mFOLFOX6) is underway.
Problem 1. Stage IIIB sigmoid colon adenocarcinoma s/p resection
Problem 2. Coronary artery disease with TVD s/p anterior STEMI and PCI
Problem 3. Chronic HBV exposure (anti-HBc reactive)
Problem 4. Renal function and electrolyte trend
Problem 5. Liver function and biliary tree abnormality
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
[note]
Diffuse large B cell lymphoma (DLBCL): Suspected first relapse or refractory disease in patients who are medically fit - 2025-05-28 - https://www.uptodate.com/contents/diffuse-large-b-cell-lymphoma-dlbcl-suspected-first-relapse-or-refractory-disease-in-patients-who-are-medically-fit
This 66-year-old male with relapsed/refractory follicular lymphoma (grade 3A, stage IV, FLIPI = 5) is undergoing salvage immunochemotherapy with modified R-ESHAP. He presents with recurrent post-renal AKI (requiring right PCN), sepsis with recent shock episode (norepinephrine use prior to transfer on 2025-05-27), persistent neutropenia, fluctuating cytopenias, anal abscess status post fistulectomy, poorly controlled diabetes (HbA1c 9.1%), and atrial fibrillation with RBBB. On 2025-05-28, he shows signs of clinical stabilization under Sintum (ceftazidime) and Targocid (teicoplanin), improved hemodynamics (BP 95–109/68–80 mmHg, SpO2 100%) and afebrile status (35.9–36.1°C). However, persistent inflammation (CRP 21.0 mg/dL on 2025-05-28) and worsening anemia/thrombocytopenia are concerning.
Problem 1. Acute Kidney Injury (post-renal/intrinsic)
Problem 2. Sepsis with Neutropenia
Problem 3. Hematologic Toxicity (Anemia, Thrombocytopenia, Neutropenia)
Problem 4. Diabetes Mellitus, Poorly Controlled
Problem 5. Cardiopulmonary Compromise
Problem 6. Anal Abscess and Post-Fistulectomy Care
[MedRec]
[exam finding]
[MedRec]
[consultation]
This 68-year-old woman with advanced pancreatic head ductal adenocarcinoma (pT2N2, stage III), status post-Whipple procedure (2024-06-05) and portal vein stenting (2024-06-14), recently completed chemotherapy on 2025-05-15 and was transferred for terminal care. She experienced a fall with right frontal scalp trauma on 2025-05-23. Currently, she presents with multiple critical complications including: neutropenia with recovery trend, thrombocytopenia, persistent jaundice and hypoalbuminemia, metabolic alkalosis with hypoxemia, and signs of sepsis with elevated inflammatory markers and mixed urinary infection. Hospice co-care has been arranged due to deteriorating general status and ECOG 4. Do-not-resuscitate orders and advance directives were completed.
Problem 1. Sepsis and possible infection focus
Problem 2. Hematological suppression: neutropenia, thrombocytopenia
Problem 3. Hepatobiliary dysfunction: jaundice, hypoalbuminemia
Problem 4. Electrolyte disturbances: hyponatremia, hypokalemia, hypocalcemia
Problem 5. Acid-base and oxygenation status (based on venous blood gas)
[exam finding]
[consultation]
This is a 78-year-old male with a history of hypertension and spinal surgery, presenting with dizziness, nausea/vomiting, epigastric discomfort, and recent constitutional symptoms. Abdominal CT (2025-05-26) suggests necrotic paraaortic and retroperitoneal lymphadenopathy with liver metastases and gallbladder wall thickening, raising suspicion for gallbladder (GB) cancer. He presents with electrolyte disturbances (notably severe hyponatremia and hypocalcemia), liver dysfunction, and elevated inflammatory markers. There is also evidence of low blood osmolality and inappropriately concentrated urine. Clinical and imaging findings suggest paraneoplastic syndrome or hepatic dysfunction-associated SIADH. Surgical intervention is deferred due to advanced disease spread.
Problem 1. Suspected gallbladder cancer with lymph node and liver metastases
Problem 2. Hyponatremia
Problem 3. Hypocalcemia
Problem 4. Constitutional symptoms and nutritional deficiency
Problem 5. Pain and functional status
[lab data]
2025-04-29 Bone Marrow Chromosome Analysis
2025-04-15 B2-Microglobulin 36471 ng/mL
2025-04-14 HBsAg Nonreactive
2025-04-14 HBsAg (Value) 0.33 S/CO
2025-04-14 Anti-HBs 57.98 mIU/mL
2025-04-14 Anti-HBc Reactive
2025-04-14 Anti-HBc-Value 1.11 S/CO
2025-04-14 Anti-HCV Reactive
2025-04-14 Anti-HCV Value 2.63 S/CO
2025-04-11 FKLC 145.20 mg/L
2025-04-11 FLLC 173.23 mg/L
2025-04-11 FK/FL ratio 0.84 ratio
2025-04-09 Protein, total 10.4 g/dL
2025-04-09 Albumin 27.8 %
2025-04-09 Alpha-1 3.5 %
2025-04-09 Alpha-2 9.3 %
2025-04-09 Beta 6.1 %
2025-04-09 Gamma 53.3 %
2025-04-09 M-peak Positive
2025-04-09 A/G Ratio 0.40
2025-04-09 IgG/A/M Kappa/Lambda IgG + Kappa chain
2025-04-07 IgG (blood) 7193 mg/dL
2025-04-07 IgA 40 mg/dL
2025-04-07 IgM <20 mg/dL
2025-04-02 SCC (NM) 3.32 ng/mL
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
The patient is a 54-year-old male with multiple myeloma (IgG/Kappa, ISS stage III), end-stage renal disease on chronic hemodialysis, chronic atrial fibrillation, and heart failure with preserved ejection fraction (HFpEF). He is currently on VTd chemotherapy (bortezomib, dexamethasone, thalidomide) and antiviral prophylaxis with Vemlidy (tenofovir alafenamide). He was admitted for fever (39.6°C on 2025-05-22) and elevated hs-Troponin I (79.9 pg/mL), raising concern for possible infectious and/or cardiac complications. Imaging on 2025-05-21 suggests cardiomegaly and left lower lung field opacity. The myeloma remains uncontrolled, and the patient’s condition is complicated by anemia, electrolyte disturbances, and systemic inflammation.
Problem 1. Fever with left lung opacity
Problem 2. Active multiple myeloma (IgG/Kappa)
Problem 3. End-stage renal disease on hemodialysis
Problem 4. Atrial fibrillation and cardiac risk
Problem 5. Anemia and inflammatory state
[exam finding]
[MedRec]
2024-12-18 ~ 2024-12-25 POMR Neurology Chen GuiQuan
2024-08-27 ~ 2024-09-12 POMR General and Gastroenterological Surgery Wu ChaoQun
2023-03-07 ~ 2023-03-10 POMR Urology Luo QiWen
2022-08-22 ~ 2022-08-25 POMR Urology Luo QiWen
[consultation]
[surgical operation]
[chemotherapy]
The patient is a 75-year-old male with stage IB signet-ring cell adenocarcinoma of the gastric antrum (pT1bN1cM0), status post laparoscopic subtotal gastrectomy with D2 lymphadenectomy on 2024-08-29, currently undergoing adjuvant chemotherapy with FOLFOX, most recently administered on 2025-05-23. He has a background of chronic hepatitis B and a prior ischemic stroke (left MCA infarct on 2024-12-17). The patient remains ECOG 1 with stable vital signs. Recent labs on 2025-05-22 reveal microcytic anemia, mild thrombocytopenia, and CKD stage 2 with stable liver function. No signs of infection or recurrence noted on imaging or physical exam.
Problem 1. Gastric cancer (post-gastrectomy, stage IB)
Problem 2. Microcytic anemia (below not posted)
Problem 3. Thrombocytopenia
Problem 4. Chronic hepatitis B
Problem 5. Renal function (CKD stage 2)
Problem 6. Ischemic stroke history
This is a 75-year-old male with a history of gastric adenocarcinoma with signet-ring cell differentiation (pT1bN1, Stage IB) post-laparoscopic subtotal gastrectomy with D2 lymph node dissection on 2024-08-29. He has since received 8 cycles of FOLFOX chemotherapy, adjusted in later courses due to cytopenia. The patient also experienced a focal left MCA infarct on 2024-12-17, with residual partial aphasia. Comorbidities include chronic hepatitis B, right bundle branch block, LV diastolic dysfunction, and cerebral atrophy with small vessel disease. His recent labs on 2025-03-24 reveal persistent microcytic anemia, mild hypoalbuminemia, and renal function within CKD stage 2 range. Current vital signs are stable.
Problem 1. Gastric Adenocarcinoma (Post-Gastrectomy, pT1bN1, Stage IB)
Problem 2. Ischemic Stroke (Left MCA Infarct, 2024-12-17)
Problem 3. Microcytic Anemia (Chronic, Symptomatic)
Problem 4. Chronic Hepatitis B
Problem 5. Mild Renal Dysfunction (CKD Stage 2) (not posted)
Problem 6. Cardiac Conduction and Structural Abnormalities
[lab data]
2025-02-17 FLT3-D835 (BM) Undetectable
2025-02-17 NPM1 mutation (qual) (BM) Presence of mutation
2025-02-10 FLT3/ITD mutation (BM) Undetectable
2025-02-10 JAK2 mutation (quan) 0.00 %
2024-12-27 HLA B-high 58:01
2024-12-27 HLA C-high 01:02
2024-12-27 HLA C-high 03:02
2024-12-27 HLA DQ-high 02:01
2024-12-27 HLA DQ-high 04:01
2024-12-27 HLA DR-high 03:01
2024-12-27 HLA DR-high 04:05
2024-11-20 HLA A-high 24:02
2024-11-20 HLA A-high 26:01
2024-11-20 HLA B-high 54:01
2024-11-20 HLA B-high 58:01
2024-11-20 HLA C-high 01:02
2024-11-20 HLA C-high 03:02
2024-11-20 HLA DQ-high 02:01
2024-11-20 HLA DQ-high 04:01
2024-11-20 HLA DR-high 03:01
2024-11-20 HLA DR-high 04:05
2024-11-07 FLT3-D835 (BM) Undetectable
2024-11-05 FLT3/ITD (BM) Undetectable
2024-11-05 NPM1 (qual)(BM) Presence of mutation
2024-11-05 JAK2 (quan) 0.00 %
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
This 43-year-old woman with myelodysplastic syndrome (MDS), subtype RAEB-II and confirmed NPM1 mutation (bone marrow 2025-02-17), is demonstrating evolving features consistent with acute myeloid leukemia (AML) transformation based on sustained peripheral blood blasts >20% (peaking at 50.0% on 2025-04-22) and markedly elevated WBC (up to 91.47 ×10^3/uL on 2025-05-15). Her clinical course includes recurrent anemia, persistent thrombocytopenia, episodic neutrophilia, systemic inflammation (CRP up to 20.3 mg/dL), and initiation of Vidaza plus Venetoclax from 2025-05-21. Neurological complications include arthropathy and possible sensory neuropathy. Hemodynamically stable as of 2025-05-22 but functionally impaired (ECOG PS 3).
Problem 1. AML transformation from MDS-RAEB-II
Problem 2. Inflammatory and infectious status
Problem 3. Anemia and thrombocytopenia
Problem 4. Arthropathy and neuropathic pain (not posted)
Problem 5. Peripheral neuropathy and neuromusculoskeletal pain
Problem 5. Peripheral neuropathy (old one, not posted)
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
2025-05-20 - _________________________________________ oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3885mg NS 500mL 46hr (FOLFOX 85% due to old age. no more NHI Avastin left)
2025-04-23 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3885mg NS 500mL 46hr (Avastin + FOLFOX 85% due to old age)
2025-03-24 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3890mg NS 500mL 46hr (Avastin + FOLFOX 85% due to old age)
2025-03-07 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3860mg NS 500mL 46hr (Avastin + FOLFOX 85% due to old age)
2025-02-14 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 460mg NS 250mL 2hr + fluorouracil 2800mg/m2 3200mg NS 500mL 46hr (Avastin + FOLFIRI 30% off)
2025-01-21 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 450mg NS 250mL 2hr + fluorouracil 2800mg/m2 3160mg NS 500mL 46hr (Avastin + FOLFIRI 30% off)
2024-12-27 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 460mg NS 250mL 2hr + fluorouracil 2800mg/m2 3220mg NS 500mL 46hr (Avastin + FOLFIRI 30% off)
2024-12-06 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 450mg NS 250mL 2hr + fluorouracil 2800mg/m2 3190mg NS 500mL 46hr (Avastin + FOLFIRI 30% off)
2024-11-08 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 460mg NS 250mL 2hr + fluorouracil 2800mg/m2 3200mg NS 500mL 46hr (Avastin + FOLFIRI 30% off)
2024-10-14 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 460mg NS 250mL 2hr + fluorouracil 2800mg/m2 3200mg NS 500mL 46hr (Avastin + FOLFIRI 30% off)
2024-09-23 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 460mg NS 250mL 2hr + fluorouracil 2800mg/m2 3200mg NS 500mL 46hr (Avastin + FOLFIRI 30% off)
2024-09-05 - bevacizumab 5mg/kg 300mg NS 100mL 90min (Avastin)
2024-08-19 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 460mg NS 250mL 2hr + fluorouracil 2800mg/m2 3200mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-07-30 - _________________________________________ irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 466mg NS 250mL 2hr + fluorouracil 2800mg/m2 3264mg NS 500mL 46hr (FOLFIRI 30% off)
This 68-year-old woman with metastatic rectal adenocarcinoma (ypT3N1aM1a, G3, stage IVA) has undergone definitive CCRT and APR (2023-11-30), with disease progression documented on PET (2024-07-18: left pelvic and inguinal LN) and CT (2025-02-17: new left iliac LN). Since 2024-07-30, she has been receiving chemotherapy, initially with Avastin + FOLFIRI, later transitioned to Avastin + FOLFOX (from 2025-03-07), and currently continued on FOLFOX alone (NHI covered Avastin exhausted after 2025-04-23).
Recent PET (2025-03-10) shows dissociated response with regression in prior lesions but a new metabolically active iliac LN. Her organ functions remain stable: renal (eGFR 109.88 mL/min/1.73m² on 2025-05-20), hepatic (ALT 12 U/L, AST 19 U/L), and hematologic (WBC 5.5, Hgb 11.1 g/dL, PLT 209), with mild anemia. Glucose variability is noted (114–238 mg/dL). BP is mostly well-controlled (120–175 mmHg systolic), though pulse remains low-normal (HR 60–76 bpm). She remains in ECOG PS 1, afebrile, with good appetite and no nausea/vomiting during most recent FOLFOX cycle (2025-05-20 to 2025-05-22).
Problem 1. Metastatic rectal adenocarcinoma with dissociated PET response
Problem 2. Hematologic toxicity and anemia (not posted)
Problem 3. Chemotherapy-associated hepatotoxicity (resolved) (not posted)
Problem 4. Cardiovascular: Bradycardia and controlled hypertension (not posted)
Problem 5. Glycemic fluctuation under steroid exposure
Problem 6. Chemotherapy-induced nausea (controlled) (not posted)
Since the last review on 2024-12-30, the patient with metastatic rectal adenocarcinoma (ypT3N1aM1a, stage IVA, left inguinal and pelvic LN metastases) has continued chemotherapy (Avastin + FOLFIRI switched to Avastin + FOLFOX on 2025-03-07). Over the past 2.5 months, key developments include:
Problem 1: Disease Progression with New Metastatic LN (2025-02-17 CT)
Problem 2: Cardiovascular Issues – Persistent Bradycardia and Hypertension
Problem 3: Blood Glucose Variability
Active Medication Review
| Medication | Concerns |
|---|---|
| Bevacizumab (Avastin) | Hypertension risk; monitor BP closely. |
| Oxaliplatin (FOLFOX) | Neuropathy risk; monitor for sensory changes. |
| Atenolol (Urosin) | Likely contributing to bradycardia; needs dose review. |
| Olmesartan + Candesartan | Dual ARB therapy; consider reducing to monotherapy. |
| Canagliflozin, Gliclazide, Metformin | Risk of hypoglycemia vs. post-chemo hyperglycemia; monitor trends. |
| Dexamethasone (PRN for chemo) | May be causing hyperglycemia and BP spikes. |
Key Adjustments:
Final Considerations
Next Steps
Conclusion
[Summary]
The patient is a 68-year-old woman with advanced rectal adenocarcinoma (ypT3N1aM1a, stage IVA) involving the anus and metastatic left inguinal lymph node.
She has undergone multiple interventions, including concurrent chemoradiotherapy (CCRT), laparoscopic abdominoperineal resection (APR), and systemic chemotherapy with Avastin (bevacizumab) and FOLFIRI.
The disease has shown progression as of 2024-07-18 per PET/CT. Key issues include hypertension, sinus bradycardia, chemotherapy-related side effects, renal concerns (microalbuminuria due to bevacizumab), and a history of type 2 diabetes mellitus (T2DM), hyperlipidemia, and hypertension.
Lab results and clinical parameters suggest generally stable organ function but highlight specific areas of concern.
[Problems]
Problem 1: Rectal Adenocarcinoma with Metastasis (ypT3N1aM1a, stage IVA)
Problem 2: Sinus Bradycardia with Hypertension
Problem 3: Chemotherapy-Associated Hematuria
[Medication Review]
Current Medications
Medication Adjustments:
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
This 68-year-old man with high-grade, nonintestinal-type left sinonasal adenocarcinoma (T1N2bM1, stage IVc) status post tumor excision (2024-05-31), presents post-auto-PBSCT (2025-04-09), currently on self-paid palliative chemotherapy with Taxotere (docetaxel). Disease is metastatic to left parotid, mandible (perineural spread), lymph nodes, lung, and bone (notably C6). Based on MRI (2025-04-11), disease burden is stable. He received Cycle 6 docetaxel on 2025-05-22 with stable performance (ECOG PS 1), afebrile, no pain, and preserved appetite. Labs show stable renal function (eGFR ~34.3 mL/min/1.73m² on 2025-05-21), chronic mild anemia (HGB 10.2 g/dL on 2025-05-21), normokalemia, hyperuricemia, and hypo-HDL pattern. He is maintained on Vemlidy (tenofovir alafenamide) for HBV reactivation prophylaxis. A bone scan and radiotherapy planning are underway.
Problem 1. Metastatic sinonasal adenocarcinoma (T1N2bM1, stage IVc)
Problem 2. Bone metastasis (C6 vertebral body)
Problem 3. Chronic hepatitis B carrier
Problem 4. Anemia
Problem 5. Chronic renal dysfunction
Problem 6. Hyperuricemia
[exam finding]
[MedRec]
[surgical operation]
[Subjective]
medication counseling for adjuvant endocrine therapy
prior therapy and surgical history
[Objective]
oncologic staging and pathology
current treatment
labs and comorbid status
[Assessment]
early-stage HR+/HER2– breast cancer with AI initiation
potential adverse effects of AI requiring monitoring
medication safety and adherence considerations
[Plan / Recommendation]
optimize AI therapy monitoring and supportive measures
education and follow-up
This is a postmenopausal woman with hormone receptor (HR)-positive, HER2-negative early-stage (pT1aNx) invasive ductal carcinoma of the left breast, coexisting with ductal carcinoma in situ (DCIS) involving the resection margin after partial mastectomy (2025-05-19). The invasive tumor is ER/PR strongly positive, HER2 negative, and Ki-67 low (10%). No nodal assessment was performed. Background history includes hypertension, dyslipidemia, insomnia, and peptic ulcer disease, all under pharmacologic management. Bone scan (2025-04-30) revealed a solitary skull hot spot and multiple suspected benign skeletal lesions, pending follow-up. Liver and renal function are preserved. ECG abnormalities (2025-05-15) raise concern for chronic cardiac ischemia. Current staging is pT1aNxM0, Stage IA (AJCC 8th).
Problem 1. Breast cancer (HR+/HER2–, pT1aNxM0)
Problem 2. Cardiovascular disease and abnormal ECG
Problem 3. Hepatobiliary lesions and bone scan abnormality
Problem 4. General metabolic and hematological status
[MedRec]
[exam finding]
[MedRec]
[immunochemotherapy]
[Note]
Pertuzumab, trastuzumab, and hyaluronidase: Drug information - 2025-05-21 - https://www.uptodate.com/contents/pertuzumab-trastuzumab-and-hyaluronidase-drug-information
Systemic therapy regimens for HER2-positive breast cancer: Neoadjuvant trastuzumab, pertuzumab, carboplatin, and docetaxel followed by adjuvant trastuzumab - 2025-05-21 - https://www.uptodate.com/contents/image?imageKey=ONC%2F96372
Cycle length: Every 21 days.
Duration of therapy: Prior to surgery (neoadjuvant portion of treatment), administer carboplatin, docetaxel, trastuzumab, and pertuzumab every 21 days for six cycles. Following surgery, adjuvant treatment consists of 11 cycles of trastuzumab alone to complete one year of trastuzumab.
Regimen
Systemic therapy regimens for HER2-positive metastatic breast cancer: Pertuzumab, trastuzumab, and docetaxel - 2025-05-21 - https://www.uptodate.com/contents/image?imageKey=ONC%2F96342
Cycle length: Every 21 days.
Duration of therapy: Until disease progression or unacceptable toxicity.
Regimen
[Subjective]
Chemotherapy-related diarrhea and pain
Anemia-related symptoms and education
Bone metastasis management
Hepatitis B risk and antiviral prophylaxis
[Objective]
Laboratory trends
Medication
Treatment summary
[Assessment]
Post-chemotherapy diarrhea and mucosal toxicity
Chemotherapy-induced anemia
Bone metastasis
Hepatitis B risk under immunosuppression
[Plan / Recommendation]
Symptom monitoring and medication counseling
Anemia follow-up and management
Bone-modifying agent initiation
HBV prophylaxis
This is a 72-year-old female with HER2-positive (ER+, PR−, Ki-67: 70%) left breast invasive carcinoma (NST type), stage IV (cT3N0M1) with confirmed metastases to the right supraclavicular lymph nodes, bone (including S1-S2, L5, costovertebral junctions), and possibly mediastinal lymph nodes (PET 2025-04-08; CT 2025-04-07; Bone Scan 2025-04-09). She began systemic therapy with the TCHP regimen on 2025-04-26 and received a second cycle with Phesgo and docetaxel on 2025-05-19. Complications have included chemotherapy-induced diarrhea (hospitalization 2025-05-01 to 2025-05-06), transient neutropenia, anemia, hyponatremia, and cancer-related fatigue with reduced oral intake. Functional performance has declined (ECOG from 0 to 1), and her weight has dropped from 58 kg to 54.3 kg over 1 month. Despite this, major organ functions (renal, liver, cardiac) remain relatively preserved.
Problem 1. Metastatic HER2-positive left breast cancer (stage IV, cT3N0M1)
Problem 2. Chemotherapy-related complications (diarrhea, neutropenia, fatigue)
Problem 3. Anemia, possibly multifactorial
Problem 4. Electrolyte imbalance – hyponatremia
Problem 5. Bone metastasis with pain and limited mobility
[Justification based on NCCN 2025 Guidelines]
The treatment plan in Problem 1 does not violate the 2025 NCCN guidelines for HER2-positive breast cancer. On the contrary, it is well-aligned with current NCCN recommendations.
Patient Context:
NCCN-Supported Regimen:
According to the NCCN 2025 Guidelines for HR-positive, HER2-positive Stage IV breast cancer, the preferred first-line systemic therapy includes:
This combination is based on the CLEOPATRA trial, which demonstrated significant improvement in progression-free and overall survival for HER2-positive metastatic breast cancer.
Furthermore, Carboplatin is also an acceptable substitution in taxane-based HER2 regimens when clinically appropriate or when tolerance/toxicities are a concern.
Phesgo, a fixed-dose subcutaneous formulation of trastuzumab and pertuzumab, is approved and endorsed in the NCCN guideline as a substitute for the separate IV agents, offering comparable efficacy and safety.
Conclusion:
[exam finding]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
This is an 80-year-old male with a history of stage IIIB gastric adenocarcinoma (pT4aN3a cM0) status post laparoscopic radical subtotal gastrectomy (2024-09-09) and concurrent high-grade invasive urothelial carcinoma (cT4aN0M0) of the bladder, previously treated with definitive chemoradiotherapy. He is currently undergoing adjuvant chemotherapy with FOLFOX (20% dose reduction due to age), and just started C5D1 (2025-05-19 to 2025-05-21). Recent labs indicate stable renal function (Cr 1.26 mg/dL, eGFR 58.38 mL/min/1.73m² on 2025-05-19), persistent normocytic anemia (HGB 10.8 g/dL), resolved thrombocytopenia, and normal liver enzymes. Tumor markers CEA and CA-199 remain within moderate range. His current ECOG PS is 1, with no reported GI complaints or systemic symptoms. He remains hemodynamically stable. Comorbidities including chronic HBV (anti-HBc+) and hyperuricemia/gout are under treatment.
Problem 1. Gastric Adenocarcinoma pT4aN3a cM0, stage IIIB
Problem 2. Myelotoxicity and Normocytic Anemia
Problem 3. Renal Function and Chemotherapy Safety
Problem 4. Cardiovascular and Perfusion Risk (not posted)
Problem 5. Bladder Cancer Surveillance Post-CCRT
This is a complex, elderly male patient with a history of advanced gastric adenocarcinoma (pT4aN3aM0, stage IIIB) status post subtotal gastrectomy with D2 LN dissection (2024-09-09) and concurrent invasive high-grade urothelial carcinoma (cT4aN0M0, stage IIIA) managed with pelvic RT + platinum-based chemotherapy. Currently, the patient is undergoing FOLFOX chemotherapy with a 20% dose reduction due to age. On 2025-03-28, he is clinically stable (ECOG PS 1) with no abdominal pain, tolerating intake, and passing diarrhea the day before. His recent labs show stable renal and liver function, normonatremia, hypocalcemia (2.12 mmol/L on 2025-03-27), and mild normocytic anemia (HGB 10.6 g/dL) with thrombocytopenia (PLT 101 x10³/uL). Surveillance tumor markers (CEA, CA-199) have shown slight fluctuation but remain within a moderate range. Recent imaging revealed stool impaction (KUB 2025-03-27) and increased lower lung markings (CXR 2025-03-27), which requires clinical correlation. The patient has a complex oncologic and cardiovascular background, including atherosclerosis, paroxysmal atrial fibrillation, left vocal cord palsy, and prostate hyperplasia.
Problem 1. Advanced Gastric Adenocarcinoma (pT4aN3aM0, stage IIIB)
Problem 2. Invasive High-Grade Urothelial Carcinoma of Bladder (cT4aN0M0, stage IIIA)
Problem 3. Renal Function and Chemotherapy Safety
Problem 4. Hematologic Status
Problem 5. Cardiovascular Comorbidity
[exam finding] (not completed)
[MedRec]
[surgical operation]
[chemotherapy]
2025-05-19 - cetuximab 500mg/m2 700mg 90min + oxaliplatin 85mg/m2 100mg D5W 250mL 12hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 400mg/m2 500mg NS 500mL 1hr IP (left in the abdomen for 24 hours, then drained using a vacuum bottle) + fluorouracil 2800mg/m2 3800mg NS 500mL 46hr (cetuximab + FOLFOX)
2025-04-14 - [oxaliplatin 300mg/m2 408mg + mitomycin-C 18mg/m2 25mg] IP 90min
2025-02-19 - cetuximab 500mg/m2 700mg 90min + oxaliplatin 85mg/m2 100mg D5W 250mL 12hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3800mg NS 500mL 46hr (cetuximab + FOLFOX)
2025-01-07 - cetuximab 500mg/m2 700mg 90min + oxaliplatin 85mg/m2 100mg D5W 250mL 12hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3800mg NS 500mL 46hr (cetuximab + FOLFOX)
2024-12-04 - cetuximab + FOLFOX
2024-11-15 - cetuximab + FOLFOX
2024-10-24 - cetuximab + FOLFOX
2024-10-01 - cetuximab + FOLFOX
2024-09-12 - cetuximab + FOLFOX
2023-11-23 - cetuximab + FOLFOX
2023-11-01 - cetuximab + FOLFOX
2023-10-05 - cetuximab + FOLFOX
2023-09-21 - cetuximab + FOLFOX
2023-05-08 - cetuximab + FOLFOX
2023-04-18 - cetuximab + FOLFOX
2023-03-31 - cetuximab + FOLFOX
2023-03-17 - cetuximab + FOLFOX
2023-03-03 - cetuximab + FOLFOX
2023-02-17 - cetuximab + FOLFOX
2023-01-30 - cetuximab + FOLFIRI
2022-12-29 - cetuximab + FOLFIRI
2022-12-14 - cetuximab + FOLFIRI
2022-11-29 - cetuximab + FOLFIRI
2022-11-10 - FOLFIRI
2022-10-24 - FOLFIRI
2022-10-06 - FOLFIRI
2022-09-21 - FOLFIRI
This 61-year-old woman with stage IVB descending colon adenocarcinoma (ypT4aN1aM1b), post extensive cytoreductive surgery and intraperitoneal chemotherapy (HIPEC on 2025-04-14), is currently receiving systemic FOLFOX plus Cetuximab therapy combined with 5-FU intraperitoneal infusion. Despite history of severe oxaliplatin hypersensitivity, infusion was resumed using prolonged administration and premedication without immediate allergic reaction. She presents with stable vital signs, tolerable clinical status (ECOG 1), borderline anemia, improving thrombocytopenia, and mild hyponatremia. The glucose profile shows mild fasting hyperglycemia likely related to steroid use. LFTs, renal function, and inflammatory markers have normalized post-op (compared to 2025-04-14 to 2025-04-17 hepatitis pattern and elevated CRP).
Problem 1. Metastatic descending colon adenocarcinoma, ypT4aN1aM1b, status post CRS + HIPEC
Problem 2. Chemotherapy-related hematologic suppression (anemia, thrombocytopenia)
Problem 3. Chemotherapy-related liver enzyme fluctuation and hepatotoxicity surveillance
Problem 4. Type 2 diabetes mellitus - mild steroid-related hyperglycemia (not posted)
Problem 5. Mild hyponatremia (not posted)
[exam finding]
[MedRec]
[immunochemotherapy]
[Concentrated IV Valproate for Fluid Restriction]
For patients requiring fluid restriction, the concentration of intravenous valproate sodium (Depakine) can be increased up to 8 mg/mL, provided that the infusion rate does not exceed 20 mg/min and the solution is diluted in at least 50 mL of a compatible diluent such as normal saline (NS) or 5% dextrose in water (D5W). (GlobalRPH)
Rationale:
Clinical Application:
Precautions:
Conclusion:
In fluid-restricted patients, administering valproate sodium at a concentration of up to 8 mg/mL in a minimum of 50 mL of compatible diluent over 60 minutes is acceptable and aligns with current guidelines.(GlobalRPH)
The Depakine 400mg/vial package insert recommends dissolving in 500mL of solution (0.8mg/mL). However, due to fluid restriction concerns, it is conservatively recommended to dissolve in 100mL (4mg/mL) and administer over 120 minutes.
References:
[exam finding]
[consultation]
This 65-year-old woman with multiple myeloma (IgA, stage III), end-stage renal disease on hemodialysis since 2023-01-12, and congestive heart failure (initial LVEF 22%, now normalized), is currently hospitalized for suspected myeloma relapse. Bone marrow biopsy on 2025-04-29 demonstrated histological features consistent with relapse, supported by rising lambda light chains and anemia. She also presents with an infected left AV graft, complicating vascular access for dialysis. Diabetes control remains suboptimal, with postprandial glucose excursions despite insulin use. Renal function is chronically impaired but stable. Cardiopulmonary and hemodynamic status are currently stable without evidence of fluid overload or respiratory compromise.
Problem 1. Multiple myeloma (IgA, relapsed)
Problem 2. End-stage renal disease with left AV graft infection
Problem 3. Anemia
Problem 4. Type 2 diabetes mellitus with hyperglycemia
Problem 5. Heart failure with preserved ejection fraction (LVEF normalized)
[exam finding]
[MedRec]
[exam finding] (not completed)
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
[exam finding]
[MedRec]
[Subjective]
medication adherence and safety monitoring
bleeding risk counseling
[Objective]
antiplatelet and cardiovascular medication review - on Bokey (aspirin 100 mg QD) and Plavix (clopidogrel 75 mg QD) - on Concor (bisoprolol 5 mg QD), Diovan FC (valsartan 80 mg QD), Crestor (rosuvastatin 10 mg QD), Spiron (spironolactone 25 mg QD)
glycemic control regimen
BP/glucose trend
recent labs and hemodynamic status
[Assessment]
medication adherence adequate
no current bleeding or cardiovascular complications
glycemic status improved, but high-risk background persists
[Plan / Recommendation]
monitor for bleeding complications
reinforce medication and lifestyle adherence
glycemic follow-up and titration
BP monitoring and threshold guidance
A 78-year-old male with a long-standing history of type 2 diabetes mellitus and hypertension presented on 2025-04-09 with NSTEMI complicated by cardiogenic shock. Coronary angiography revealed critical LM and triple-vessel disease (Syntax score 40.5) including m-LAD near-total occlusion. He underwent POBA to m-LAD and LM on 2025-04-10, required IABP support until 2025-04-13, and received CABG on 2025-04-15. He subsequently stabilized, was transferred from SICU to the ward, and was discharged on 2025-04-25 under stable condition with a comprehensive medication plan.
Problem 1. Coronary artery disease with high-risk anatomy post-NSTEMI and CABG
Problem 2. Cardiogenic shock status post-IABP support
Problem 3. Anemia and thrombocytopenia post-operatively
Problem 4. Acute inflammatory response with transient renal impairment
Problem 5. Diabetes mellitus with poor long-term control
[exam finding]
[MedRec]
[Subjective]
medication use and lifestyle
[Objective]
current pharmacotherapy (2025-05-13 SOAP)
lipid trend
recent cardiovascular interventions
LV function (2024-12-16 Echo)
[Assessment]
dual antiplatelet therapy
lipid control
lifestyle and secondary prevention
[Plan / Recommendation]
antiplatelet therapy
lipid management
lifestyle reinforcement
surveillance
This is a 45-year-old male with a significant history of ST-elevation myocardial infarction (STEMI) on 2024-12-14, due to dual-vessel coronary artery disease (CAD) involving the LCx-OM1 and LAD. He underwent staged PCI with drug-eluting stents (DES) to the LCx-OM1 and P-LCx (2024-12-14), followed by M-LAD and P-LAD stenting (2025-01-13). He remains on DAPT (aspirin + ticagrelor) with high-intensity lipid-lowering therapy (atorvastatin/ezetimibe + PCSK9 inhibitor alirocumab). He is currently clinically stable without recurrent angina, though he reports exertional dyspnea. His LV systolic function is borderline (EF ~50%) with lateral wall hypokinesia, and labs show marked LDL-C reduction post-treatment (199 → 14 → 73 mg/dL), indicating excellent lipid response.
Problem 1. Coronary Artery Disease with STEMI, post-PCI x4 DES (LCx-OM1, P-LCx, M-LAD, P-LAD)
Problem 2. Borderline LV Systolic Dysfunction with Regional Wall Motion Abnormality
Problem 3. Dyslipidemia with Recent LDL-C Normalization
Problem 4. Hypertension, well controlled
Problem 5. Active Smoking and Lifestyle Risk
Problem 6. Hypokalemia (corrected)
[exam finding]
[consultation]
[surgical operation]
[chemotherapy]
This is a 56-year-old female diagnosed with bilateral ovarian endometrioid adenocarcinoma, FIGO stage IC (pT1c3N0) and concurrent endometrial adenocarcinoma, FIGO IA2, post-debulking surgery on 2025-02-24. She is currently undergoing adjuvant chemotherapy with paclitaxel/carboplatin, having received C1 on 2025-04-18 and admitted for C2 on 2025-05-13. She remains clinically stable (ECOG PS 1) with normalized tumor markers and recovered hematologic profile. No current signs of infection, organ dysfunction, or chemotherapy-related toxicity were identified.
Problem 1. Bilateral ovarian endometrioid adenocarcinoma, pT1c3N0, FIGO stage IC, post-debulking and adjuvant chemotherapy
Problem 2. Chemotherapy-related myelosuppression (resolved)
Problem 3. Liver and renal function under chemotherapy
[lab data]
2025-02-12 CMV_IgG Reactive
2025-02-12 CMV_IgG Value 1165.6 AU/mL
2024-11-05 HLA A-high 11:02 2024-11-05 HLA A-high 33:03 2024-11-05 HLA B-high 38:02 2024-11-05 HLA B-high 58:01 2024-11-05 HLA C-high 03:02 2024-11-05 HLA C-high 07:02 2024-11-05 HLA DQ-high 05:03 2024-11-05 HLA DQ-high 06:09 2024-11-05 HLA DR-high 13:02 2024-11-05 HLA DR-high 14:54
[exam finding]
[MedRec]
[consultation]
[immunochemotherapy]
2025-03-02 cyclophosphamide 40mg/kg 3400mg NS 500mL 4hr D1-2
2025-02-20 - fludarabine 24mg/m2 50mg NS 250mL 1hr D1-5 + busulfan 3.2mg/kg 276mg NS 460mL 3hr D2-4 (PTCy TBI ATG. Fludara 20% off, poor renal function)
2024-11-19 - rituximab 375mg/m2 760mg NS 500mL 8hr D1 + ifosfamide 5000mg/m2 10000mg NS 500mL 24hr D4 + mesna 5000mg/m2 10000mg NS 500mL 24hr D4 + carboplatin AUC 5 430mg NS 100mL 3hr D4 + etoposide 100mg/m2 200mg NS 500mL 1hr D3-5 (R-ICE)
2024-10-23 - rituximab 375mg/m2 760mg NS 500mL 8hr D1 + ifosfamide 5000mg/m2 10000mg NS 500mL 24hr D4 + mesna 5000mg/m2 10000mg NS 500mL 24hr D4 + carboplatin AUC 5 430mg NS 100mL 3hr D4 + etoposide 100mg/m2 200mg NS 500mL 1hr D3-5 (R-ICE)
2023-05-30 - etoposide 500mg/m2 1000mg NS 50mL 2hr D1-4 (high dose etoposide. Once)
2022-06-02 - 2024-07-19 - Imbruvica (ibrutinib) 140mg/cap 4# QD
2022-04-11 - rituximab 375mg/m2 700mg 6hr + cisplatin 100mg/m2 190mg 24hr D2 + cytarabine 2000mg/m2 3900mg 3hr Q12H D3
2022-03-11 - rituximab 375mg/m2 730mg 8hr + cyclophosphamide 750mg/m2 1466mg 30min + doxorubicin 50mg/m2 97mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 50mg BID PO D1-5 (R-CHOP)
2022-02-08 - rituximab 375mg/m2 700mg 6hr + cisplatin 100mg/m2 190mg 24hr D2 + cytarabine 2000mg/m2 3900mg 3hr Q12H D3
2022-01-04 - rituximab 375mg/m2 738mg 8hr + cyclophosphamide 750mg/m2 1470mg 30min ………………………….. + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 50mg BID PO D1-5
2021-12-08 - ……………………………………………………….. cytarabine 2000mg/m2 3900mg 3hr Q12H D3
2021-12-07 - rituximab 375mg/m2 700mg 6hr + cisplatin 100mg/m2 190mg 24hr D2 + cytarabine 2000mg/m2 3900mg 3hr Q12H D3
2021-11-16 - rituximab 375mg/m2 730mg 8hr + cyclophosphamide 750mg/m2 1466mg 30min + doxorubicin 50mg/m2 97mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 50mg BID PO D1-5
2021-10-19 - rituximab 375mg/m2 738mg 8hr + cyclophosphamide 750mg/m2 1470mg 30min ………………………….. + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 30mg BID PO D1-5
Problem 1: Post-Allo PBSCT Immune Reconstitution and Engraftment
Problem 2: GVHD Prophylaxis – Cyclosporine A Level Monitoring
Problem 3: Thrombocytopenia
Problem 4: Electrolyte Imbalances (Mg, Ca, Na)
Problem 5: Glycemic Control in a Diabetic Post-Transplant
Problem 6: Infection Risk and Management
[evaluation of whether the post-allo PBSCT patient is ready for hospital discharge]
Final Comment: Is this patient ready for discharge?
Not quite yet.
The main barrier is platelet count (<50K) and borderline neutrophil recovery (ANC ~900). For a post-allo PBSCT patient at D+30, early discharge could be unsafe unless: - PLT reaches >50K without transfusion needs. - ANC consistently >1000/uL. - Close outpatient monitoring (labs, GVHD surveillance) is guaranteed.
What could be done before discharge: (not posted)
The patient, a 68-year-old male post-allo PBSCT (D+27 on 2025-03-25) for Mantle Cell Lymphoma (MCL), is gradually recovering from profound neutropenia. Recent data reveal:
Hematologic Reconstitution after PBSCT
GVHD Prophylaxis / Cyclosporine Management
Persistent Anemia and Thrombocytopenia
Infection Risk and Antibiotic Management
Glycemic Control
Problem 1. Profound Pancytopenia Post-AlloPBSCT
Problem 2. Cyclosporin A (CsA) Trough Level & Toxicity Risk (new data pending, not posted)
Problem 3. Diarrhea & Perianal Skin Breakdown (GVHD vs. Drug/TPN-related) (not posted)
Problem 4. Nutritional Deficiency & Refeeding Risk
Problem 5. Infection Monitoring & Antibiotic Adjustment
Updated Prioritized Issues Since 2025-03-18
Problem 1. Hematologic Recovery & Engraftment Progress
Problem 2. Cyclosporine (CsA) Trough Level Evaluation (not posted)
Problem 3. Nutritional Status & GI Function
Problem 4. Persistent Thrombocytopenia
Problem 5. Electrolyte Balance & Renal Function
Problem 6. Infection Surveillance & Antibiotic Management
Updated Insights on Prioritized Issues Since 2025-03-14
Problem 1. Post-Transplant Engraftment and Bone Marrow Recovery
Problem 2. Cyclosporine Trough Level Evaluation
Problem 3. Persistent Malnutrition and Protein Deficiency
Problem 4. Inflammatory Response and Infection Risk
Problem 5. Electrolyte Imbalances and Supplementation Needs
Final Summary of Prioritized Issues (2025-03-18)
Evaluation for Major Updates & Clinical Trends Since Last Review on 2025-03-11 (As of today 2025-03-14)
A. Key Updates and Trends (not posted)
Low-grade fever continues (BT 37.5–37.7°C) with anal pain and sore throat, raising suspicion for:
Worsening diarrhea after elemental diet, raising concern for infection-associated diarrhea (C. difficile, viral enteritis) vs. GVHD enteritis.
Cyclosporine level spiked to 404.1 ng/mL on 2025/03/13, potentially contributing to toxicity, nephrotoxicity, and immune suppression, exacerbating infection risk.
Current Infection Management:
B. Problem-Oriented Deliberation
Problem #1: Persistent Severe Pancytopenia (D+15)
Problem #2: Infection Risk with New Fever and Diarrhea
Problem #3: Cyclosporine Toxicity Risk (not posted)
Problem #4: Severe Oral Mucositis (Grade 3)
Problem #5: Nutritional Status and Metabolic Support
C. Summary of Recommendations
Overall Prognostic Considerations
Next Steps
Cyclosporine Dose Adjustment Recommendation:
[tube feeding]
Since the last review on 2025-03-07, the patient has shown changes across multiple systems:
Problem #1: Post-Haploidentical PBSCT Status (D+11)
Problem #2: Gastrointestinal Recovery and Electrolyte Imbalance
Problem #3: Grade 3 Oral Mucositis – Severe Pain and Malnutrition Risk
Problem #4: Aspiration Pneumonia (Right Lower Lobe) – Stable (not posted)
Additional Monitoring & Next Steps
Conclusion
Patient Evaluation Since Last Review (2025-03-04 → 2025-03-07 D+8 post-haploidentical PBSCT)
Problem 1: Persistent Severe Neutropenia
Problem 2: High Infection Risk (Bacterial & Fungal)
Problem 3: Severe Electrolyte Imbalances (Hypokalemia, Hyponatremia, Hypocalcemia, Hypophosphatemia)
Problem 4: Persistent Severe Thrombocytopenia
Problem 5: Liver Function Trends (Mild Recovery, But Bilirubin Rising)
Problem 6: Hyperglycemia Fluctuations
Problem 7. Diarrhea (Possible Etiologies: Electrolyte Loss, Infection, GVHD, Medications)
[Dosage Adjustment Recommendation for Atorvastatin with Cyclosporine Co-Administration]
The atorvastatin package insert states that concomitant use of cyclosporine and atorvastatin increases the bioavailability of atorvastatin, thereby raising the risk of myopathy. Therefore, it is recommended to adjust the dosage from 0.5# QD to 0.5# QOD.
Since the last evaluation on 2025-02-27, the patient has undergone haploidentical peripheral blood stem cell transplantation (PBSCT) on 2025-02-27 (D+0) and is now post-transplant D+5 (2025-03-04). The major clinical concerns in this period include:
Problem 1: Post-Transplant Cytopenia
Problem 2: Persistent Diarrhea and GI Infection Risk
Problem 3: Hepatic Dysfunction and Transaminitis
Problem 4: Electrolyte Imbalances (Hyponatremia, Hypokalemia)
Problem 5: Infection Risk and Prophylaxis
Conclusion
Since last review on 2025-02-17, the patient underwent conditioning chemotherapy (fludarabine, busulfan, cyclophosphamide), total body irradiation (TBI), and anti-thymocyte globulin (ATG) in preparation for haploidentical peripheral blood stem cell transplantation (haplo-PBSCT), which was performed on 2025-02-27 (Day 0) today.
Key developments since the last review:
Problem 1: Post-HCT Immune Reconstitution and Infection Risk
Problem 2: Hepatic Dysfunction (Post-Conditioning Transaminitis)
Problem 3: Persistent Renal Impairment
Problem 4: Thrombocytopenia and Engraftment Monitoring
Problem 5: Pulmonary Findings and Cardiac Monitoring
Summary of Next Steps
| Issue | Current Status | Action Plan |
|---|---|---|
| Post-HCT Infection Risk | Profound lymphopenia | CMV PCR monitoring, infection prophylaxis (Cravit, Micafungin, Neomycin) |
| Hepatic Dysfunction | AST/ALT elevated (647/498) | Monitor LFTs, consider VOD workup if bilirubin rises |
| Renal Function | Mild CKD | Hydration, avoid nephrotoxins |
| Thrombocytopenia | PLT 47 ×10³/uL | Monitor CBC, transfusion as needed |
| Pulmonary Findings | CXR: Possible effusion | Monitor for fluid overload, repeat imaging if needed |
Final Thoughts
The patient continues to show:
Problem 1. Persistent Bone Marrow Suppression (Anemia and Thrombocytopenia)
Problem 2. Worsening Renal Function (CKD Stage 3b)
Problem 3. Infection and Inflammation Surveillance (No Current Evidence of Active Infection)
Problem 4. Liver and Coagulation Function (Stable and Normal)
Summary of Recommendations (2025-02-17 Update, not posted)
| Problem | Current Status | Recommended Action |
|---|---|---|
| Persistent marrow suppression | Anemia (HGB 10.4), thrombocytopenia (PLT 109) | Monitor CBC, consider bone marrow biopsy (BMBx) |
| Renal impairment (CKD 3b) | Worsening Cr (1.74), eGFR 41.8 | Hydration, avoid nephrotoxins, nephrology consult if worsening |
| Infection risk (immunosuppression) | No active infection (CRP 0.1, WBC normal) | CMV PCR test, infection prophylaxis |
| Liver and coagulation function | Stable (AST/ALT, bilirubin, INR normal) | Routine monitoring |
Next Steps for Allo-PBSCT Feasibility (not posted)
The patient remains a potential candidate for allo-PBSCT, but key requirements must still be addressed:
[Assessment of Donor-Recipient Compatibility and Readiness for Haploidentical Peripheral Blood Stem Cell Transplantation (Haplo-PBSCT)]
The patient is a 66-year-old male with mantle cell lymphoma (Lugano stage IV, MIPI 6.4, intermediate risk, PS 1), type 2 diabetes mellitus, and chronic hepatitis B. He has undergone multiple lines of chemotherapy, including R-CHOP, R-DHAP, and R-ICE, and was on Imbruvica (ibrutinib) from 2022-06-02 to 2024-07-19. The most recent chemotherapy was C2 R-ICE on 2024-11-19. Current issues of concern include:
Problem 1. Persistent Bone Marrow Involvement and Cytopenia
Problem 2. Renal Impairment (CKD Stage 3)
Problem 3. Hematologic Abnormalities (Anemia, Thrombocytopenia, Lymphopenia)
Problem 4. Cardiac Conduction Abnormalities (1st Degree A-V Block)
Problem 5. Residual Lymphadenopathy and Splenomegaly (Partial Response on PET)
[Assessment for Allogeneic Peripheral Blood Stem Cell Transplant (allo-PBSCT)]
Current Indications for Allo-PBSCT
Conditions Already Met for Allo-PBSCT:
Conditions Not Yet Met (Requires Further Intervention):
This mantle cell lymphoma patient had been treated with R-CVP/R-CHOP/R-DHAP (until April 2022) and started receiving Bruton’s tyrosine kinase inhibitor ibrutinib in early June 2022 and achieved a partial response (2022-08-19 CT).
The combination of ibrutinib and venetoclax (this is not covered by National Health Insurance at present) has been shown to promote responses in patients with relapsed or refractory mentle cell lymphoma.
[exam finding]
[MedRec]
[immunochemotherapy]
The patient is a 58-year-old male with diffuse large B-cell lymphoma (Lugano stage IV, non-GCB subtype) undergoing R-miniCHOP chemotherapy (most recent on 2025-04-15), with comorbidities of CKD stage IV, diabetic nephropathy, hypertension, ischemic heart disease, and history of recurrent ascites and pleural effusion. Currently, he presents with cellulitis of the left arm, progressive anemia, hypoalbuminemia, and fluctuating renal function. His vital signs remain stable but hypertensive (BP 176/84 mmHg on 2025-05-08). Blood glucose is moderately controlled. Ongoing management includes antibiotics, insulin, and supportive care for electrolyte and mineral balance.
Problem 1. Hematologic Abnormalities (Anemia and Leukocytosis)
Problem 2. Infection: Left Arm Cellulitis
Problem 3. CKD with Electrolyte and Mineral Imbalances
Problem 4. Hypertension and Cardiovascular Risk
Problem 5. Glycemic Control
This is a 58-year-old male with a history of diffuse large B-cell lymphoma (DLBCL, Lugano stage IV, non-GCB subtype) with peritoneal involvement, chronic kidney disease (CKD stage IV), nephrotic syndrome, type 2 diabetes mellitus (T2DM) with diabetic nephropathy, hypertension, and chronic ischemic heart disease. He has undergone multiple chemotherapy regimens, including R-miniCHOP (most recently on 2025-03-20). Recent trends show progressive anemia, CKD worsening, persistent electrolyte imbalances (mild hypokalemia), and fluctuating white blood cell counts with neutrophilic predominance. His blood pressure control is suboptimal, and he has ongoing pleural effusions. The disease burden includes lymphadenopathy, ascites, and ongoing metabolic derangements.
Problem 1. Hematologic Abnormalities (Anemia, Leukocyte Variability, Thrombocytopenia Trends)
Problem 2. Worsening Chronic Kidney Disease (CKD Stage IV)
Problem 3. Uncontrolled Hypertension
Problem 4. Persistent Pleural Effusion & Ascites
Final Remarks
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
[Patient]
The patient is a 39-year-old woman with recurrent bilateral ovarian clear cell carcinoma (pT3cN0M0, FIGO stage IIIC, now stage IV with peritoneal carcinomatosis) post-debulking surgery (2023-04-20).
She is undergoing palliative chemotherapy with Q3W cycles of Avastin (bevacizumab) + Lipo-Dox (liposomal doxorubicin), now at C6 as of 2025-05-08.
Her disease remains radiographically stable per CT (2025-03-22), with chronic issues of anemia, hypomagnesemia, mild hypercalcemia, and cancer cachexia. Her general condition is ECOG 1, with stable vital signs and good tolerance of chemotherapy.
[Problems]
Problem 1. Recurrent Clear Cell Ovarian Carcinoma with Peritoneal Carcinomatosis
Problem 2. Anemia
Problem 3. Electrolyte Abnormalities: Hypercalcemia and Hypomagnesemia
Problem 4. Gastrointestinal Symptoms and Cachexia
Problem 5. Vital Signs and Port-A Status (not posted)
This is a 39-year-old woman with recurrent bilateral ovarian clear cell carcinoma (Stage IIIC, FIGO IIIC; now clinically Stage IV since 2024-02) post-debulking surgery (2023-04-20), who has received multiple lines of chemotherapy, currently on C4 Bevacizumab (Avastin) + Liposomal Doxorubicin (Lipo-Dox) as of 2025-03-24.
Since the last review (2025-02-24), she experienced:
Problem 1. Recurrent Clear Cell Ovarian Carcinoma with Peritoneal Carcinomatosis
Problem 2. Anemia (Improved but Persistent)
Problem 3. Hypomagnesemia (Refractory)
Problem 4. Hypoalbuminemia and Cancer Cachexia
Problem 5. Hypercalcemia (Improved, now mild)
Problem 6. Hyponatremia (Chronic, mild) (not posted)
Problem 7. Vital Sign Instability: Tachycardia with Recent Improvement (not posted)
The patient, a 39-year-old woman with recurrent bilateral ovarian clear cell carcinoma (pT3cN0M0, FIGO stage IIIC), is admitted on 2025-02-23 for C3 chemotherapy with Avastin (bevacizumab) + Lipo-dox (liposomal doxorubicin). She has progressive peritoneal carcinomatosis with massive ascites (CT 2024-12-12), hypercalcemia (Ca 3.07 mmol/L on 2025-02-23), and cachexia (weight loss of 5 kg over one month).
Key issues include:
Problem 1. Recurrent Ovarian Clear Cell Carcinoma with Progressive Disease
Problem 2. Hypercalcemia
Problem 3. Anemia and Thrombocytosis
Problem 4. Hyponatremia and Hypokalemia
Conclusion (not posted)
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
The patient is a 63-year-old woman with nasopharyngeal carcinoma (NPC), cT1N1M0 stage II, who has completed definitive concurrent chemoradiotherapy (2024-12-25 to 2025-02-12) and is now undergoing adjuvant chemotherapy with the PF regimen (cisplatin + fluorouracil, started 2025-03-17). Recent clinical findings indicate stable disease with mild-to-moderate sensorineural hearing loss as a complication of treatment. Laboratory trends show gradually declining renal function and progressive anemia, now with moderate normocytic anemia. Liver function and electrolytes remain stable. Her overall physical condition is good (ECOG 1), with no major acute toxicity from chemotherapy noted. Vitals are stable.
Problem 1. Nasopharyngeal carcinoma, cT1N1M0, stage II, post CCRT and ongoing adjuvant PF chemotherapy
Objective
Diagnosed with NPC cT1N1M0 stage II by MRI (2024-11-22), biopsy confirmed non-keratinizing carcinoma (2024-11-28).
Received CCRT: cisplatin 40 mg/m² weekly from 2024-12-25 to 2025-02-12 plus radiotherapy 7000 cGy/35 fractions to primary and nodal areas.
Ongoing adjuvant chemotherapy with PF regimen started 2025-03-17 (cisplatin 80 mg/m² + 5-FU 1000 mg/m², using IBW due to obesity) with cycles on 2025-03-17 and 2025-04-08.
Recent nasopharyngoscopy (2025-03-12) shows much improvement with smaller tumor; PTA (2025-03-18) shows mild to moderately severe SNHL bilaterally.
Assessment
The patient’s treatment aligns with NCCN guidelines for stage II NPC (CCRT followed by adjuvant chemotherapy considered for bulky tumor).
Local disease appears well controlled with significant shrinkage; no new symptoms or evidence of recurrence.
Sensorineural hearing loss is a recognized side effect of cisplatin therapy, which is likely the cause of the hearing findings.
No major acute complications such as severe mucositis, infections, or disease progression noted.
Recommendation
Continue planned adjuvant PF chemotherapy as scheduled (next cycle 2025-05-08).
Schedule nasopharyngoscopy after completion of adjuvant chemotherapy to assess local disease.
Monitor hearing status periodically; consider dose adjustment if ototoxicity progresses.
Consider EBV DNA monitoring for long-term follow-up as a prognostic marker.
Problem 2. Renal function impairment (likely chemotherapy-related nephrotoxicity)
Objective
eGFR has declined from 84.25 mL/min/1.73m² (2025-03-04) to 47.31 mL/min/1.73m² (2025-05-07).
Creatinine increased from 0.74 mg/dL (2025-03-04) to 1.22 mg/dL (2025-05-07).
BUN rose from 19 mg/dL (2025-03-04) to 33 mg/dL (2025-05-07).
Cisplatin cycles administered, known nephrotoxic agent.
Assessment
The gradual deterioration of renal function is likely secondary to cisplatin nephrotoxicity.
Hydration protocols and Mg supplementation were provided (MgO and MgSO4), but the cumulative nephrotoxic effect is evident.
Current renal status is at CKD stage 3a (eGFR 47 mL/min/1.73m²), requiring close monitoring to avoid further decline.
Recommendation
Consider switching cisplatin to carboplatin for further cycles if renal function worsens or hits critical thresholds (eGFR <45 or creatinine >1.5 mg/dL).
Continue hydration and magnesium supplementation; monitor renal function before and after each chemotherapy cycle.
Regularly reassess electrolyte balance and urine output.
Problem 3. Anemia (progressive, moderate normocytic anemia)
Objective
HGB dropped from 12.2 g/dL (2025-02-11) to 7.8 g/dL (2025-05-07).
RBC decreased from 3.96 x10^6/uL (2025-02-11) to 2.26 x10^6/uL (2025-05-07).
MCV has remained normal (102.7 fL on 2025-05-07), indicating normocytic anemia.
PLT count has improved (207 x10^3/uL on 2025-05-07).
Assessment
The anemia is likely multifactorial: chemotherapy-induced myelosuppression, possible chronic disease-related anemia, and nutritional factors.
No evidence of hemolysis or bleeding was reported; reticulocyte count is not available but could help clarify marrow activity.
The anemia has progressed to a level requiring intervention (>8 g/dL down to 7.8 g/dL).
Recommendation
Consider red blood cell transfusion if symptomatic or if HGB drops below 7 g/dL.
Monitor CBC weekly during chemotherapy; if persistent, consider erythropoiesis-stimulating agents.
Evaluate iron, vitamin B12, folate, and reticulocyte count to exclude reversible causes.
Problem 4. Electrolyte and metabolic balance (not posted)
Objective
Sodium: stable at 135 mmol/L (2025-05-07) vs 138 mmol/L (2025-03-04).
Potassium: 4.2 mmol/L (2025-05-07) vs 3.8 mmol/L (2025-03-04), well maintained.
Magnesium: 1.7 mg/dL (2025-05-07) vs 1.3 mg/dL (2025-03-04), improved after supplementation.
Calcium: 2.51 mmol/L (2025-05-07), within normal range.
Assessment
Overall good control of electrolytes, likely due to ongoing MgO supplementation and hydration during chemotherapy.
No major disturbances noted; stable albumin (4.0 g/dL on 2025-05-07) supports normal total calcium.
Recommendation
Continue MgO 250 mg QID as prescribed; maintain hydration and regular monitoring.
Reassess electrolytes before and after chemotherapy cycles.
Monitor for signs of hypomagnesemia, especially due to ongoing cisplatin exposure.
Problem 5. Cardiovascular status (hypertension, cardiomegaly)
Objective
History of hypertension under medical control.
BP ranged 103/68 to 142/94 mmHg (2025-05-07), fluctuating but mostly acceptable.
CXR (2025-01-08) showed cardiomegaly, atherosclerotic changes.
No reported chest pain, dyspnea, or edema.
Assessment
Blood pressure control appears mostly stable but peaks up to 142/94 mmHg are noted, warranting observation.
No evidence of decompensated heart failure; no symptoms of ischemia.
Cardiomegaly and vascular changes are chronic and monitored.
Recommendation
Continue regular antihypertensive treatment; assess compliance.
Check BP routinely during chemotherapy, as fluid management can impact BP.
Consider follow-up echocardiography if any new cardiac symptoms arise.
[MedRec]
[Subjective]
cardiovascular status
gastrointestinal and hepatobiliary status
diabetes and metabolic status
[Objective]
vital signs and general
cardiovascular
hematology and labs
current medications
[Assessment]
post-NSTEMI secondary prevention
HCC and liver cirrhosis
anemia and thrombocytopenia
diabetes and metabolic management
[Plan / Recommendation]
post-NSTEMI secondary prevention
HCC and liver cirrhosis
anemia and hematology
diabetes and metabolic management
pharmacist interventions
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
2024-09-18 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 90min
2024-08-07 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 90min
2024-07-09 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 90min
2024-06-11 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 90min
2024-05-07 - liposome doxorubicin 50mg/m2 80mg D5W 250mL 90min
2024-04-17 - liposome doxorubicin 50mg/m2 80mg D5W 250mL 90min
2024-03-27 - liposome doxorubicin 50mg/m2 80mg D5W 250mL 90min
2024-02-27 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 90min
2023-12-21 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
2023-12-07 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 90mg D5W 250mL 1hr
2023-11-30 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
2023-10-18 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr
2023-10-11 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
2023-09-26 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr
2023-09-19 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
2023-09-05 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr
2023-08-29 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
2023-08-15 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 90mg D5W 250mL 1hr
2023-08-08 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
2023-07-11 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr
2023-06-27 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr
2023-06-20 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
2023-06-06 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr
2023-05-30 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
2023-05-16 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr
……….
2020-12-29 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr
2020-12-15 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr
2020-12-02 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 60mg/m2 100mg D5W 250mL 1hr
2020-11-20 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 30mg/m2 50mg D5W 250mL 1hr
2020-10-29 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + docetaxel 30mg/m2 50mg D5W 250mL 1hr
2020-10-07 - irinotecan 80mg/m2 125mg NS 500mL 1.5hr
2020-09-18 - irinotecan 80mg/m2 125mg NS 500mL 1.5hr + temozolomide 140mg PO D1-2
[Subjective]
cardiovascular status post PCI
oncology background
[Objective]
vital signs and physical findings
recent labs (selected)
medication profile (2025-04-17 prescription)
[Assessment]
antithrombotic therapy
heart failure management
diabetes/diuretic agent
dyslipidemia
GI protection
oncologic considerations
[Plan / Recommendation]
antithrombotic strategy
heart failure and cardiac medications
diabetes/diuretic agent
dyslipidemia
GI protection
oncology follow-up
adherence and education
[MedRec]
[consultation]
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[immunochemotherapy]
This is a 70-year-old woman with stage IVc ascending colon adenocarcinoma (cT4aN2aM1c) with liver, bone, adrenal gland, duodenum, peritoneal metastasis, obstructive jaundice (status post ERBD 2025-02-03), bilateral hydronephrosis (status post bilateral DJ stent insertion 2025-01-15), and ECOG 2. She has received Avastin (bevacizumab) + FOLFIRI chemotherapy (2025-02-14, 2025-03-05), palliative radiotherapy (C5-T1 spine 3000cGy/10fx, ampulla of Vater tumor 2000cGy/8fx), and port-A was clear on 2025-05-06. Currently stable for further chemotherapy, under magnesium sulfate and sodium bicarbonate infusion, with vital signs stable (BT 36.6°C, BP 148/80 mmHg, PR 104 bpm, SpO2 98% at 2025-05-06 12:22), urine culture showing gram positive cocci 1000 CFU/cc (2025-05-03).
Problem 1. Malignant neoplasm of ascending colon (stage IVc)
Problem 2. Renal dysfunction with bilateral hydronephrosis
Problem 3. Electrolyte imbalance (hypomagnesemia, metabolic acidosis)
Problem 4. Infection risk and urinary tract infection
Problem 5. Cardiopulmonary status (not posted)
[exam finding]
[MedRec]
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
Patient: 56-year-old female
Diagnosis: Bilateral ovarian high-grade serous carcinoma (pT3cN0, FIGO
Stage IIIC), secondary malignant neoplasm of large intestine and rectum,
post-debulking surgery on 2025-01-10, currently receiving paclitaxel +
carboplatin chemotherapy
Reason for Visit: Follow-up on paclitaxel-related adverse reaction and
general treatment tolerance
S – Subjective
O – Objective
A – Assessment
P – Plan, Recommendation
The patient is a 56-year-old woman with bilateral ovarian high-grade serous carcinoma (pT3cN0, FIGO Stage IIIC) with known invasion to the sigmoid colon (pathology 2025-01-13), status post optimal debulking surgery on 2025-01-10, followed by chemotherapy with paclitaxel and carboplatin since 2025-03-07. She had a documented anaphylactic reaction to paclitaxel on 2025-03-06 but successfully rechallenged subsequently with enhanced premedication. She was admitted on 2025-05-05 for febrile episode with chills; initial CRP was elevated at 18.5 mg/dL (2025-05-04) despite normal urinalysis and negative COVID-19 and influenza screening. Blood cultures were pending, and broad-spectrum antibiotics Brosym (cefoperazone/sulbactam) were initiated. She remains afebrile on 2025-05-06 (36.2’C), hemodynamically stable (BP 109/65 mmHg), and has mild anemia (HGB 8.4 g/dL), normal neutrophil count (74.4%), elevated transaminases (ALT 124 U/L, AST 112 U/L), and rising CRP (18.2 mg/dL on 2025-05-05). Her overall clinical status appears stable but with concerns for persistent inflammation and potential hepatotoxicity.
Problem 1. Infection / Fever of Unknown Origin
Problem 2. Hepatic dysfunction
Problem 3. Anemia
Problem 4. Chemotherapy-induced peripheral neuropathy
Problem 5. Electrolyte balance (not posted)
[Management and Patient Education on Chemotherapy Agents for Paclitaxel-Related Adverse Reaction]
Bedside Visit: Today 2025-03-07, at approximately 14:00
During a bedside visit, the patient, along with her husband and two friends, was present. The patient stated that the symptoms experienced the previous day had completely resolved.
Incident Summary (2025-03-06):
Treatment Adjustment: Today, the attending physician reordered paclitaxel with modifications:
However, the infusion had not yet been administered as the patient had other scheduled examinations.
Patient Education:
[exam finding]
[MedRec]
[Subjective]
medication adherence and tolerability
- patient reported good medication adherence
- consistent with wife’s report: patient remains physically active (park
walking and slow jogging)
- no subjective complaints of adverse drug reactions since last pharmacy
consultation on 2024-12-19
- no signs of bleeding or bruising observed or reported
- denies hematuria, melena, or gingival bleeding
- skin ecchymosis (–), gum bleeding (–)
lifestyle and diet
- maintains regular physical activity (daily slow jogging, morning
walk)
- diet includes balanced intake: moderate vegetables, adequate protein,
low starch
- continues home use of avocado oil, low intake of cookies/bread
- adequate hydration and high fruit consumption reported
[Objective]
medication regimen (as of 2025-04-02)
- Bokey (Aspirin) 100 mg QD
- Brilinta (Ticagrelor) 90 mg BID
- Concor (Bisoprolol) 2.5 mg QD (half tab of 5 mg)
- Crestor (Rosuvastatin) 10 mg QD
- Ezetrol (Ezetimibe) 10 mg QD
vital signs and labs
- BP 119/76 mmHg, HR 72 bpm (2025-04-02)
- HbA1c 6.5% (2025-03-25)
- LDL-C 74 mg/dL, Cholesterol total 129 mg/dL, TG 102 mg/dL
(2025-03-25)
- Creatinine 0.85 mg/dL, eGFR 96.15 mL/min/1.73m² (2025-03-25)
- Platelet count 195 x10^3/uL, INR 0.98, APTT 24.5 sec (2025-01-19)
adverse drug reaction surveillance
- no signs of renal, hepatic, or hematological toxicity
- ALT 22 U/L (2025-03-25), BUN 21 mg/dL
[Assessment]
secondary prevention post-NSTEMI with triple-vessel CAD
- DAPT with Aspirin + Ticagrelor continued appropriately
- no bleeding complications reported
- lipid control goal met with LDL-C <70 mg/dL nearly achieved
- Crestor + Ezetrol combination appropriate for enhanced LDL
lowering
- heart rate and blood pressure well controlled under beta-blocker
therapy
- glycemic control acceptable (HbA1c 6.5%)
- renal function stable, no electrolyte imbalance
- good medication adherence, high motivation and physical
performance
[Plan / Recommendation]
continue current pharmacotherapy
- continue DAPT (Aspirin + Brilinta)
- monitor bleeding risk, especially with prolonged use
- continue statin + ezetimibe for aggressive lipid control
- continue bisoprolol for rate and cardiac remodeling control
monitoring
- follow-up labs in 3 months: lipid profile, HbA1c, renal and liver
panel
- ensure long-term safety of polypharmacy
- continue monitoring for bleeding signs (GI, urinary, skin)
- reinforce use of medication alert card for DAPT use, especially
pre-surgery
lifestyle and counseling
- reinforce regular exercise and hydration
- consider diabetes education session if glucose values begin trending
upward
- advise patient to consult before starting any over-the-counter
supplements
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
This is a 65-year-old female with high-grade serous carcinoma of the right ovary, FIGO Stage IIIB (pT3bN0 [if cM0]) diagnosed on 2024-12-27. She underwent optimal debulking surgery (R0 resection), followed by adjuvant chemotherapy with paclitaxel plus carboplatin Q3W, initiated on 2025-02-09. Tumor markers, especially CA-125, have declined rapidly and are now within normal limits (CA-125 4.73 U/mL on 2025-04-18), with no radiologic evidence of residual or recurrent tumor (Gynecologic sonography 2025-04-26). Recent labs show hematologic nadirs with recovery, preserved renal and liver function, and stable nutritional and electrolyte status. The current clinical status is consistent with an ongoing treatment response without relapse.
Problem 1. Ovarian Serous Carcinoma, FIGO IIIB, Post Debulking + Chemo (C4)
Problem 2. Hematologic Suppression and Recovery During Chemotherapy
Problem 3. Renal, Hepatic, and Electrolyte Status
The patient is a 65-year-old female with right ovarian high-grade serous carcinoma (HGSOC), diagnosed as pStage IIIB (pT3bN0 [if cM0]) following debulking surgery on 2024-12-27. She recently began chemotherapy with Taxol (paclitaxel) plus Carboplatin on 2025-02-09 (C1D1, Q3W). Her postoperative recovery has been uneventful, and she has a Port-A for chemotherapy administration. The pathology indicated metastatic disease involving the peritoneum, omentum, and rectal surface but no lymph node involvement. Her ECOG performance status is 0, with manageable symptoms. Current problems include the malignancy, potential insomnia, and an upper lip herpes lesion.
Problem 1. Right Ovarian Cancer (HGSOC, FIGO Stage IIIB, Post-Surgery)
Problem 2. Insomnia
Problem 3. Herpes Lesion on Upper Lip
Problem 4. Postoperative Follow-Up and Monitoring
[MedRec]
[surgical operation]
[Subjective]
medication adherence and concerns - patient reported consistent use of prescribed medications - includes insulin (Apidra and Toujeo), antihypertensives, lipid-lowering agents, thyroid hormone, and antibiotics - patient stated that home blood pressure readings have recently become more unstable - plans to document these readings and discuss with Cardiac Surgeon Dr. Xu at the next follow-up in May 2025 - erythropoietin therapy is administered during dialysis sessions on Thursdays - dialysis team determines need for dosing based on lab monitoring
glycemic and wound-related feedback - patient reported that post-cardiac surgery, home-measured blood glucose levels have been more stable compared to earlier periods - no current complaint of wound-related symptoms following the 2025-04-09 sternal debridement and closure
[Objective]
medication list and pharmacologic therapy - cardiovascular - Blopress (candesartan), Nebilet (nebivolol), Caduet (amlodipine/atorvastatin), Plavix FC (clopidogrel), Bokey (aspirin) - antidiabetics - Apidra (insulin glulisine), Toujeo (insulin glargine), Ozempic (semaglutide) - endocrine - Eltroxin (levothyroxine) 3# QW12345 + 4# QW67 - infection - Curam (amoxicillin/clavulanic acid) 1# QD 8D (completed) - analgesics and others - Acetal (acetaminophen), Pentop (pentoxifylline), Takepron (lansoprazole), Through (sennoside), Tramacet (tramadol/acetaminophen)
laboratory monitoring - renal: creatinine 6.19 mg/dL, eGFR 7.44 mL/min/1.73m² (2025-04-07) - thyroid: TSH 1.090 uIU/mL, Free T4 1.300 ng/dL (2025-04-18) - glycemic: HbA1c 7.9% (2025-03-11); patient-reported trend improving - hematology: HGB persistently low (8.4 g/dL on 2025-04-17), ferritin 525.8 ng/mL (2025-03-07) - inflammatory: CRP improved (2.3 mg/dL on 2025-03-06)
[Assessment]
multimorbidity pharmacotherapy - polypharmacy regimen aligned with ESRD, post-CABG, T2DM, and hypothyroidism - thyroid replacement is biochemically sufficient - renal dosing consideration appropriate - erythropoietin support administered as needed during dialysis, likely explaining absence of documented ESA prescription - persistent anemia with HGB < 9 g/dL likely chronic and multifactorial
blood pressure instability - patient-reported instability in home BP readings may reflect evolving post-CABG hemodynamic adaptation - multiple antihypertensives in use; potential for optimization pending cardiology input
diabetes therapy - combination of basal-bolus insulin with GLP-1 agonist may be intensive in ESRD - HbA1c suboptimal but trending better per patient - risk-benefit balance needs review especially if glycemic lability recurs
wound infection management - sternal wound debridement and primary closure performed on 2025-04-09 - completed 8-day Curam course; no signs of recurrence reported
[Plan / Recommendation]
hypertension follow-up - encourage continued home BP recording - bring complete log to 2025-05 visit with Dr. Xu for possible antihypertensive regimen adjustment - review for possible postural changes or dialysis-related fluctuations
anemia and ESA optimization - continue monitoring via dialysis center with Thursday lab checks - recommend coordination between nephrology and pharmacy if additional support needed - consider rechecking iron panel in Q2 2025
diabetes management - current regimen appears adequate with patient-reported glucose stabilization - evaluate hypoglycemia risk and A1c trend at next endocrinology visit - consider CGM if hypoglycemia unawareness is suspected
medication reconciliation and review - continue current polypharmacy plan; no immediate duplication or interaction flagged - reassess need for Pentop vs GI prophylaxis (Takepron) if symptom-free - maintain thyroid hormone dosing; repeat TFT in ~3 months
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
This 77-year-old woman with stage IIIB adenocarcinoma of the proximal transverse colon (pT4aN1b, G2, LVI+, PNI+, CRM+), status post right hemicolectomy (2024-05-16), has demonstrated peritoneal recurrence with progression to carcinomatosis and liver/lung metastases (CT 2025-03-13). After an initial FOLFOX course, chemotherapy was shifted to FOLFIRI plus Avastin (bevacizumab) from 2024-09-26 to 2025-03-10. Currently admitted for ascites and symptomatic hyponatremia (Na 116 mmol/L on 2025-04-29), she shows signs of persistent inflammation, hypoalbuminemia, normocytic anemia, and poorly controlled hyperglycemia, raising concern for further cancer progression, possible infection, and nutritional compromise.
Problem 1. Peritoneal carcinomatosis and metastatic colon adenocarcinoma
Problem 2. Hyponatremia
Problem 3. Anemia and leukocytosis
Problem 4. Hyperglycemia
Problem 5. Hypoalbuminemia and nutritional compromise
[CEA and CA199 doubling: consider updating imaging]
Hyponatremia and hypomagnesemia were observed and appropriately supplemented.
The patient has received 3 sessions of FOLFOX (with 80% oxaliplatin dose) at approximately 28-day intervals, with the last session on 2024-08-22. The eGFR has remained around 70 ml/min/1.73m² over the past few months, so no dose adjustment is needed.
Notably, both CEA and CA199 markers have doubled in the past month, suggesting that updating imaging may be necessary to assess disease progression.
2024-08-13 CEA (NM) 7.470 ng/ml
2024-07-09 CEA (NM) 2.764 ng/ml
2024-06-14 CEA (NM) 4.450 ng/ml
2024-04-27 CEA 118.16 ng/ml
2024-08-13 CA-199 (NM) 53.183 U/ml
2024-07-09 CA-199 (NM) 24.645 U/ml
2024-06-14 CA-199 (NM) 46.408 U/ml
[MedRec]
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
The patient is a 67-year-old male with metastatic adenocarcinoma of the ascending colon (pT3N0M1b, stage IVB, dMMR with BRAF V600E mutation) status post right hemicolectomy (2024-10-30) and ongoing systemic chemotherapy with A-FOLFIRI + bevacizumab since late 2024. PET (2025-04-21) and chest CT (2025-03-05) show no new evidence of disease progression, with stable small lung metastases and no FDG-avid lung nodules. CEA levels have remained stable. He has experienced intermittent chemotherapy-induced neutropenia and anemia but remains functionally compensated with stable renal and hepatic functions (labs 2025-04-25). Blood pressure remains suboptimally controlled despite dual antihypertensive therapy. Currently, no critical organ dysfunction is observed, but vigilant monitoring is still necessary.
Problem 1. Metastatic Colorectal Cancer - Treatment Response and Disease Status
Problem 2. Chemotherapy-Induced Anemia and Hematologic Status
Problem 3. Hypertension and Cardiovascular Risk under Antiangiogenic Therapy
Would you like me to also draft a structured progress note (“POMR
style”) summarizing this into a clinical document?
It might help if you are preparing a report or simulated case file!
The patient, a 67-year-old male with metastatic adenocarcinoma of the ascending colon (pT3N0M1b, stage IVB, dMMR) with lung metastases, is undergoing systemic chemotherapy with A-FOLFIRI. Since the last review on 2024-12-23, his treatment course has continued with some modifications in irinotecan dosing, and updated imaging and laboratory findings provide a more comprehensive view of his current status. Additional concerns include cardiovascular monitoring, persistent mild anemia, and treatment-related toxicities.
Problem 1: Metastatic Colorectal Cancer - Disease Status & Treatment Response
Problem 2: Chemotherapy-Induced Anemia & Hematologic Trends
Problem 3: Cardiovascular Risk & Blood Pressure Management
Medication Review (not posted)
| Medication | Indication | Appropriateness | Concerns/Adjustments |
|---|---|---|---|
| A-FOLFIRI | Metastatic CRC | Standard per guidelines | Ongoing irinotecan dose adjustment needed. Monitor for toxicity. |
| Amtrel (amlodipine/benazepril) 5/10 mg QD | Hypertension | Partially effective | Consider dose increase or alternative/additional antihypertensive. |
| Apolin (hydralazine) 25 mg PRN Q12H | BP control | Inconsistent efficacy | Switch to scheduled dosing if needed. |
| Promeran (metoclopramide) 3.84 mg TIDAC | Nausea/Vomiting | Appropriate | Monitor for tardive dyskinesia with prolonged use. |
| Pariet (rabeprazole) 20 mg QD | GERD | Appropriate | Long-term use should be reviewed periodically. |
| B-Complex (B1, B2, B6, nicotinamide) 1 mL IV QD | Nutritional support | Appropriate | No significant concerns. |
| Metoclopramide 10 mg/2 mL IV PRN Q6H | Breakthrough nausea | Appropriate | PRN use limits risk of extrapyramidal symptoms. |
[Key Summary]
The patient, a 67-year-old male, has adenocarcinoma of the ascending colon with lung metastasis (pT3N0M1b, stage IVB) and is mismatch repair deficient (dMMR). He has a history of right hemicolectomy on 2024-10-30 and port-A implantation on 2024-11-20. Recent chemotherapy with A-FOLFIRI and bevacizumab (2024-12-20) was initiated, with a 20% dose reduction for irinotecan due to toxicity concerns. Imaging findings confirm bilateral lung metastases, consolidation, and hepatic vascular blushes. He also has hypertensive heart disease, gastroesophageal reflux disease (GERD), and a past surgical history of cholecystectomy (2018-10-23).
Laboratory values on 2024-12-20 showed no significant hepatic or renal impairment (eGFR 84.05 mL/min/1.73m², AST 18 U/L, ALT 20 U/L). However, a mild anemia persists (HGB 10.5 g/dL), and thrombocytosis (PLT 500 × 10³/uL) may indicate systemic inflammation or a paraneoplastic process.
[Problem-Oriented Comments]
[Medication Review]
[lab data]
2025-04-15 CEA (NM) 2.900 ng/ml
2025-03-14 CEA (NM) 3.940 ng/ml
2025-02-13 CEA (NM) 6.700 ng/ml
2025-01-16 CEA (NM) 5.550 ng/ml
2024-12-25 CEA (NM) 4.180 ng/ml
2024-11-28 CEA (NM) 2.750 ng/ml
2024-10-30 CEA (NM) 1.880 ng/ml
2024-10-04 CEA (NM) 3.175 ng/ml
2024-09-03 CEA (NM) 3.382 ng/ml
2024-08-13 CEA (NM) 2.183 ng/ml
2024-07-16 CEA (NM) 2.372 ng/ml
2024-06-25 CEA (NM) 1.939 ng/ml
2024-06-04 CEA (NM) 1.690 ng/ml
2024-05-07 CEA (NM) 1.649 ng/ml
2024-04-17 CEA (NM) 1.597 ng/ml
2024-03-12 CEA (NM) 2.682 ng/ml
2024-02-20 CEA (NM) 2.331 ng/ml
2024-01-30 CEA (NM) 1.980 ng/ml
2024-01-17 CEA (NM) 3.715 ng/ml
2024-01-03 CEA (NM) 3.334 ng/ml
2023-12-07 CEA 3.00 ng/mL
2023-11-10 CEA 3.03 ng/mL
2023-10-12 CEA 4.25 ng/mL
2023-07-25 CEA 2.31 ng/mL
2023-09-20 HBsAg (NM) Negative
2023-09-20 HBsAg Value (NM) 0.422
2023-09-20 Anti-HBc (NM) Positive
2023-09-20 Anti-HBc Value (NM) 0.01
2023-09-20 Anti-HCV (NM) Negative
2023-09-20 Anti-HCV Value (NM) 0.042
2023-09-20 Anti-HBs (NM) Positive
2023-09-20 Anti-HBs value (NM) 46.4 mIU/mL
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
PharmaCloud data indicates that the patient has only been to our hospital within the last three months. Our urologist prescribed a refill of Harnalidge (tamsulosin) on 2023-09-26, and the medication is currently being used without any issues.
[exam finding]
[MedRec]
[consultation]
[immunochemotherapy]
Patient Evaluation
Problem 1. Intrahepatic cholangiocarcinoma with lung and bone metastases
Problem 2. Renal dysfunction and electrolyte balance
Problem 3. Anemia and bone marrow suppression
Problem 4. Type 2 diabetes mellitus with poor glycemic control
Problem 5. Cardiovascular comorbidity: atrial fibrillation and mitral regurgitation
This is a 73-year-old man with intrahepatic cholangiocarcinoma (ICC) with lung and bone metastases, underlying liver cirrhosis (Child-Pugh A), atrial fibrillation, hypertension, type 2 diabetes mellitus, and prior stroke. He was admitted for Port-A insertion and first-time chemotherapy. He has declined lung biopsy but underwent a CT-guided liver biopsy confirming adenocarcinoma consistent with cholangiocarcinoma.
Recent workup shows: - Liver tumor (4.9 cm, S2-3), multiple lung nodules, bone lesions (rib cage, T-spine) - Atrial fibrillation with slow ventricular response, moderate-to-severe mitral regurgitation - Elevated HBV DNA (950,000 IU/mL) and now on Vemlidy (tenofovir alafenamide) - Mildly reduced renal function (eGFR 62.48 mL/min/1.73m²) - Borderline low sodium (134 mmol/L) - Recent imaging suggests possible early lung metastases and progressive hepatic disease
Problem 1: Intrahepatic Cholangiocarcinoma with Lung and Bone Metastases (Stage IV)
Problem 2: Hepatitis B Virus (HBV) Reactivation Risk
Problem 3: Atrial Fibrillation and Valvular Heart Disease
Problem 4: Lung Nodules – Metastatic vs. Primary?
Problem 5: Bone Lesions – Metastatic vs. Degenerative?
Final Treatment Plan Summary
[Comparison of “Durvalumab + Gemcitabine + Cisplatin”, “Pembrolizumab + Gemcitabine + Cisplatin”, and “Gemcitabine + Cisplatin” in This BTC Patient]
Background & Context
Efficacy Comparison
| Regimen | Overall Survival (OS) | Progression-Free Survival (PFS) | Key Clinical Trial |
|---|---|---|---|
| GemCis | 11.7 months (median) | 5.7 months (median) | ABC-02 Trial |
| D-GemCis | 12.8 months (median) | 7.2 months (median) | TOPAZ-1 Trial |
| P-GemCis | 12.7 months (median) | Not significantly different | KEYNOTE-966 Trial |
Safety and Toxicity Profile
| Regimen | Common Adverse Effects | Immune-Related Adverse Events (irAEs) |
|---|---|---|
| GemCis | Neutropenia, anemia, fatigue, nausea, hepatotoxicity | None |
| D-GemCis | Similar to GemCis | Mild to moderate immune-related toxicities (e.g., hepatitis, colitis, thyroiditis, pneumonitis) |
| P-GemCis | Similar to GemCis | Immune-related toxicities, potential for severe irAEs |
Do We Need PD-L1 Testing Before Immunotherapy? (below not posted)
Considerations for This Specific Patient
Final Treatment Recommendation
Summary Table of Recommendations
| Treatment Plan | Recommended for This Patient? | Rationale |
|---|---|---|
| D-GemCis | Preferred choice | Best survival benefit, minimal added toxicity |
| P-GemCis | Alternative option | Good survival benefit, slightly less robust PFS |
| GemCis alone | Only if frail or refuses immunotherapy | Standard therapy but lower survival |
| PD-L1 testing | Not required | No impact on treatment selection |
Conclusion
[MedRec]
[exam finding]
[MedRec]
[chemotherapy]
[exam finding]
[chemotherapy]
[exam finding]
[MedRec]
[surgical operation]
[chemotherapy]
This is an 82-year-old male with acute myeloid leukemia (AML) diagnosed on 2025-03-18, complicated by pancytopenia, hemodialysis-dependent ESRD, HCAP, and multiple AV shunt interventions. He has had multiple episodes of anemia and thrombocytopenia requiring transfusions, and has received low-dose cytarabine (2025-03-25 to 2025-03-27). Despite ongoing infection control with various antibiotics, his condition is complicated by severe malnutrition, hypoalbuminemia, and suspected lower extremity soft tissue infection. He is now on enteral tube feeding and a DNR/comfort care pathway has been signed (2025-04-02).
Problem 1. Acute Myeloid Leukemia
Problem 2. Infection (HCAP, Fungal Risk)
Problem 3. ESRD with AV Shunt Complications
Problem 4. Hematologic Support (Anemia and Thrombocytopenia)
Problem 5. Nutritional Insufficiency and GI Support (not posted)
Problem 6. Cardiopulmonary Status and Hemodynamics
[Posanol (posaconazole) tube feeding]
Posanol (posaconazole) suspension form is not available in this hospital. Since the Posanol (posaconazole) tablet package insert does not explicitly specify it as a delayed-release tablet, it is recommended that if the medication needs to be administered via tube feeding, the simple suspension method might be used. Additionally, please also adjust the dosing from the original 3# QD to 1# TID.
This is an 82-year-old male with a complex medical history including acute myeloid leukemia (AML, newly diagnosed on 2025-03-18), end-stage renal disease (ESRD) on hemodialysis, type 2 diabetes mellitus, atrial fibrillation with pacemaker, and prior AV shunt interventions. He was admitted on 2025-03-21 for fever and abdominal pain, with CXR showing bilateral pulmonary infiltrates and clinical suspicion of pneumonia. He received Tapimycin (piperacillin/tazobactam) and later low-dose cytarabine (AraC) SC from 2025-03-24 for AML. He remains hemodynamically stable but has ongoing pancytopenia, elevated inflammatory markers, and poor oral intake.
Problem 1. Acute Myeloid Leukemia (newly diagnosed)
Problem 2. ESRD with metabolic complications
Problem 3. Infection – Suspected pneumonia
Problem 4. Invasive fungal infection – Suspected
Problem 5. Nutritional insufficiency
Problem 6. Type 2 Diabetes Mellitus
Problem 7. Cardiovascular disease (AF + Heart failure)
[exam finding]
[MedRec]
[immunochemotherapy]
[exam finding]
[MedRec]
[chemotherapy]
This 64-year-old woman with right triple-negative breast cancer (ER 0%, PR 0%, HER2 0%, Ki-67 75%) underwent partial mastectomy with axillary dissection (ypT2N2M1, stage IV) and has experienced widespread metastases (lung, liver, bone, lymph nodes) since 2024-12-23 (CT 2024-12-23, PET 2024-12-27). She is on 3rd-line palliative chemotherapy with weekly Paclitaxel since 2025-03-11 after prior treatment with EC x4, discontinued Taxotere due to ILD, surgery, and Halaven x7. She has anemia, persistent leukopenia, transient CRP elevation, and evidence of metastatic bone pain and neurologic symptoms (CT 2025-04-15, Bone scan 2025-03-26, NCV 2025-03-11). Renal and hepatic functions remain stable. Imaging (CT 2025-04-15) now shows C5 bone destruction. Her interstitial lung disease is stable. Overall, disease remains active and symptomatic, warranting close monitoring and possible regimen reevaluation.
Problem 1. Disease Progression in Triple-Negative Breast Cancer (TNBC)
Problem 2. Hematological Suppression (Neutropenia and Anemia)
Problem 3. Renal and Hepatic Function (not posted)
Problem 4. Urinary Tract Inflammation (Resolved) (not posted)
Problem 5. Bone Metastasis with Neurological Implication
[MedRec]
[Subjective]
medication adherence and symptom status - patient reported no current chest discomfort, dyspnea, or palpitations - noted improved exercise tolerance since discharge - denies dizziness or lightheadedness - bowel habit regular with current use of Through (sennoside) - no abdominal discomfort or constipation - medication adherence high - takes all prescribed medications as instructed, aware of PRN Uretropic (furosemide) threshold - no missed doses or adverse effects reported
[Objective]
cardiovascular medication - Bokey (aspirin), Brilinta (ticagrelor): dual antiplatelet therapy continued appropriately post-PCI - Concor (bisoprolol): low dose (1.25 mg) maintained with hold instructions if HR < 60 or SBP < 90 - Crestor (rosuvastatin): lipid-lowering for secondary prevention - Cordarone (amiodarone): low-dose for rhythm control in paroxysmal AF - Ivabradine: initiated during admission, not included in discharge list - stopped
heart failure therapy - Jardiance (empagliflozin): continued for HFmrEF with preserved renal function (eGFR 97.17 on 2025-04-14) - Uretropic (furosemide): 0.5# PRN if BW > 63 kg, appropriate for volume control post-decompensation - Nexium (esomeprazole): gastroprotection due to DAPT - Through (sennoside): regularized bowel movement support
labs and trends - renal function stable and improved (eGFR 84.3 → 97.17 mL/min/1.73m² from 2025-04-09 to 2025-04-14) - electrolytes WNL (Na 138, K 3.7 mmol/L on 2025-04-14) - NT-proBNP initially elevated (4737 pg/mL on 2025-04-05) - hs-Troponin I peaked (10026.8 pg/mL on 2025-04-05), trending down
[Assessment]
post-MI secondary prevention - current pharmacotherapy aligns with ACC/AHA guidelines - DAPT, beta-blocker, statin, SGLT2i all present - Cordarone for rhythm control reasonable short term; monitor thyroid/hepatic profiles
heart failure optimization - heart failure regimen includes beta-blocker, SGLT2i, diuretic (PRN), and patient education - symptoms stable and improving - patient engaged with cardiopulmonary rehab
medication safety and interactions - drug duplication or interactions not identified - Cordarone and Brilinta interaction (increased bleeding risk) noted but monitored - QT prolongation risk with Cordarone—ECG monitoring should be ensured - renal and electrolyte status favorable; diuretic strategy well individualized
[Plan / Recommendation]
support safe medication use and monitoring - reinforce indication and adherence to Bokey, Brilinta, Concor, and Jardiance - provide education on bleeding signs, orthostasis, hypoglycemia, and dehydration - recommend lab follow-up: - renal/electrolyte panel in 1–2 weeks - TSH, LFTs, ECG within 4–6 weeks for Cordarone safety monitoring
optimize heart failure outcomes - emphasize continued self-monitoring (weight, symptoms, BP/HR) - educate on PRN Uretropic use based on daily weight - encourage compliance with rehab and gradual activity increase
ensure long-term cardiovascular protection - encourage lipid panel recheck and HbA1c reassessment in 3 months - assess if further intensification (e.g., addition of ACEi/ARB or Vericiguat) needed - promote lifestyle changes: low-sodium diet, smoking cessation if applicable, routine exercise
[lab data]
2025-02-26 CD45+Total leukocyte 341547 /uL
2025-02-26 %CD34+ 2.23 %
2025-02-26 CD34+ Count 7600 /uL
2025-02-26 CD45+Total leukocyte 9806 /uL
2025-02-26 %CD34+ 2.07 %
2025-02-26 CD34+ Count 203 /uL
2025-02-25 CD45+Total leukocyte 122264 /uL
2025-02-25 %CD34+ 2.08 %
2025-02-25 CD34+ Count 2542 /uL
2025-02-25 CD45+Total leukocyte 3000 /uL
2025-02-25 %CD34+ 1.55 %
2025-02-25 CD34+ Count 46 /uL
2025-02-12 RPR Nonreactive
2025-02-12 β-HCG 1.8 mIU/mL
2025-02-12 HIV Ab-EIA Nonreactive
2025-02-12 Anti-HIV Value 0.06 S/CO
2025-02-12 Anti HTLV I/II Nonreactive
2025-02-12 Anti HTLV I/II Value 0.09 S/CO
2025-02-12 CMV IgM Nonreactive
2025-02-12 CMV IgM Value 0.05 Index
2025-02-12 CMV_IgG Reactive
2025-02-12 CMV_IgG Value 172.2 AU/mL
[exam finding]
[MedRec]
[surgical operation]
[immunochemotherapy]
Problem 1. Relapsed Diffuse Large B-Cell Lymphoma (DLBCL), non-GCB, Double Expressor
Problem 2. Bone Marrow Suppression & Hematologic Recovery Post-Chemotherapy
Problem 3. Infection Risk and Antimicrobial Prophylaxis
Problem 4. Glycemic Control and Diabetes Management
Problem 5. Electrolyte Management (Focus on Magnesium)
Problem 6. Cardiovascular Monitoring
[Patient Summary]
Th e patient, a 67-year-old female with a history of diffuse large B-cell lymphoma (DLBCL), diabetes mellitus (DM), and hypertensive heart disease, has experienced recurrent lymphoma involving the left breast and axillary lymph nodes as of 2024-07-31.
She is currently undergoing chemotherapy with R-GemOx (rituximab, gemcitabine, and oxaliplatin) for relapsed DLBCL, with stable general condition but persistent disease activity in imaging studies (CT, PET).
Notable findings include historical impaired left ventricular relaxation (2024-08-23), evidence of glucose hypermetabolism in PET (2024-08-08), and mild hyperglycemia with suboptimal glycemic control. There is no significant bone marrow involvement per biopsy on 2024-08-22.
The patient exhibits anemia with a downward trend in hemoglobin, potentially chemotherapy-related thrombocytosis (2025-01-05), and recent glucose elevation requiring titration of insulin (2025-01-06). Despite a history of aggressive lymphoma treatment since 2018, recurrent disease has impacted prognosis and necessitated ongoing management.
[Problem Comments]
Problem 1: Relapsed Diffuse Large B-Cell Lymphoma (DLBCL)
Problem 2: Suboptimal Glycemic Control
Problem 3: Impaired Cardiac Function
Problem 4: Chemotherapy-Induced Anemia and Thrombocytosis
Problem 5: History of Multinodular Goiter and Thyroid Nodules
[MedRec]
[Subjective]
The daughter came to consult on behalf of her mother (the patient).
anticoagulant medication education - patient was prescribed Lixiana (edoxaban 30mg) QD starting 2025-04-23 for stroke control/prevention in atrial fibrillation - explained that patient has AF (SOAP 2025-04-21), prior old infarcts (CT 2025-04-22), and risk of thromboembolism
bowel habit and diet - patient experiences chronic constipation - currently induces diarrhea every other day by drinking milk - has tried over-the-counter probiotics but without benefit - daily vegetable and fruit intake is low - aware of need for more fiber but no consistent dietary adjustment yet
[Objective]
brain imaging - CT (2025-04-22): large calcified meningioma (5.4cm) compressing right cerebellum; smaller frontal lesion with edema; old infarcts in bilateral cerebral lobes
current medication - Lixiana (edoxaban 30mg) QD x14 days - also on Uretropic (furosemide), Const-K ER (potassium chloride), Cordarone (amiodarone), and Eltroxin (levothyroxine), among others (SOAP 2025-04-21)
labs and renal function - eGFR 65.77 mL/min/1.73m² (2024-12-24), supports Lixiana standard dosing - PLT 154 x10³/uL, INR 1.08 (2024-12-22), no bleeding diathesis noted
[Assessment]
edoxaban initiation justified - AF, history of stroke, and CHA₂DS₂-VASc ≥2 support anticoagulation - Lixiana (edoxaban) 30mg QD appropriate considering renal function and bleeding risk
patient lacks understanding of constipation management - laxative misuse (inducing diarrhea with milk) may impact bowel regularity and nutrient absorption - low fiber intake likely contributes to constipation and may limit gut flora balance despite probiotic use
[Plan / Recommendation]
reinforce Lixiana (edoxaban) education and precautions - remind patient to take Lixiana at the same time daily, with or without food - avoid double dosing if missed; skip if not within 12 hours - advise on bleeding signs: unexplained bruising, blood in stool/urine, prolonged bleeding - caution about concurrent use of NSAIDs or antiplatelets
support bowel health via diet - recommend increasing fiber-rich vegetables and fruits gradually - promote natural prebiotic effect of fiber to support probiotic flora - discourage self-induced diarrhea as a means of managing constipation - consider fiber supplements or safer laxative alternatives under physician guidance
monitor adherence and bleeding - follow-up in 1–2 weeks for tolerability and side effects - consider referral to dietitian if bowel habits remain poorly controlled despite fiber advice
[MedRec]
[MedRec]
[Subjective]
- 2025-04-23 telephone follow-up attempted with patient; no one answered
at residence. Contact was established with the patient’s son.
- The son reported that a friend had recently recommended Coenzyme Q10,
asking whether it was beneficial, and also expressed concerns regarding
the high cost of such health supplements.
- The patient has not been fully adherent to prescribed DOAC therapy,
citing irregular intake.
[Objective]
- The patient is status post DES placement in LAD on 2025-03-22, with a
diagnosis of NSTEMI, paroxysmal atrial fibrillation, and SSS with
pacemaker (POMR 2025-03-19 to 2025-03-25).
- Current anticoagulation: Lixiana FC (edoxaban 30mg QD).
- As of 2025-04-09, poor adherence to DOAC noted in cardiology
outpatient documentation.
- No documented allergy to Coenzyme Q10 or drug-nutrient interaction
alerts in current medication regimen.
[Assessment]
- Medication adherence: Nonadherence to DOAC post-DES raises concern for
stent thrombosis or stroke risk in the setting of atrial
fibrillation.
- CoQ10 inquiry: There is no contraindication to concomitant use of
CoQ10 and edoxaban. However, there is no strong evidence of
cardiovascular benefit in this context, and the high cost may pose an
unnecessary financial burden.
- Education gap: Family may not fully understand the critical importance
of uninterrupted anticoagulation following coronary stent placement.
[Plan]
- Re-emphasized to the son the lifesaving necessity of strict adherence
to DOAC therapy, especially after DES implantation and in atrial
fibrillation.
- Advised that Coenzyme Q10 is not contraindicated but not essential,
and benefits remain unproven for this indication; high cost should be
considered before purchase.
- Suggested in-person consultation or home visit if nonadherence
continues.
- Will reattempt direct phone contact with the patient to reinforce
counseling.
- Documented counseling and will update cardiology team during next
scheduled case review.
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
Problem 1. Bone marrow suppression after chemotherapy
Problem 2. Renal and hepatic function monitoring during chemotherapy
Problem 3. Chemotherapy adverse effect management (supportive care) (not posted)
Problem 4. Electrolyte balance (not posted)
Problem 5. Surveillance of NPC recurrence
This is a 64-year-old male with a history of nasopharyngeal carcinoma (NPC), nonkeratinizing undifferentiated type, initially stage II, treated with adjuvant chemoradiotherapy >10 years ago, though treatment was incomplete. He experienced local recurrence in the left neck and underwent modified radical neck dissection on 2024-10-07, revealing rypT0N1 disease with extranodal extension (+). He subsequently completed concurrent chemoradiotherapy (2024-11-29 to 2025-01-14) and is now undergoing adjuvant chemotherapy with PF3 regimen, with two cycles completed as of 2025-03-27.
Laboratory results suggest stable renal and liver function, mild post-chemotherapy leukopenia, and preserved hematologic and electrolyte profiles. Imaging and endoscopy show no overt recurrence in the nasopharynx, with prior FDG-PET-avid cervical node proven malignant (surgically resected).
Problem 1. Locoregional recurrence of nasopharyngeal carcinoma (NPC), status post multimodal therapy
Problem 2. Bone marrow suppression (post-chemotherapy leukopenia)
Problem 3. Renal and hepatic function during chemotherapy
Problem 4. History of traumatic thoracic injury (rib fractures and lung wedge resection)
[exam finding]
[MedRec]
[consultation]
[radiotherapy]
2025-01-16 ~ 2025-03-18 - 4500cGy/25 fractions of the pelvic to paraaortic area, 5040cGy/28 fractions of the cervical tumor, and 7020cGy/39 fractions of the cervicla tumor bed.
[chemotherapy]
Problem 1. Metastatic Cervical Cancer (T3bN2M1)
Problem 2. Hematological Abnormalities: Anemia and Thrombocytopenia
Problem 3. Renal Dysfunction
Problem 4. Electrolyte Imbalance and QT Prolongation Risk
Problem 5. Infection and Inflammation Surveillance
Problem 6. Cardiovascular Monitoring (not posted)
Problem 7. Endocrine and Nutritional Status
This is a 67-year-old woman with poorly differentiated adenocarcinoma of the uterine cervix, stage T3bN2M1 (AJCC 9th edition) (MRI 2025-01-06, pathology 2025-01-07), presenting with lung, bone, and nodal metastases (CT 2025-01-09, MRI 2025-01-06). She has received concurrent chemoradiotherapy (CCRT) and is undergoing palliative chemotherapy with carboplatin ± bevacizumab. She has chronic HBV infection (Anti-HBc reactive, HBsAg non-reactive, 2025-02-07) and a history of liver cirrhosis. Her clinical course is complicated by chronic anemia, thrombocytopenia, progressive CKD, mild electrolyte disturbances (hypocalcemia, hypomagnesemia), and systemic inflammation with intermittent elevation of CRP. ECG on 2025-03-21 revealed prolonged QT, necessitating close electrolyte and ECG monitoring. Despite metastatic disease, vital signs remain stable (as of 2025-03-24), and no recent infection signs were evident (PCT 0.16 ng/mL on 2025-03-24).
Problem 1. Metastatic Cervical Cancer (T3bN2M1)
Problem 2. Chronic Anemia
Problem 3. Thrombocytopenia
Problem 4. Progressive Chronic Kidney Disease (CKD)
Problem 5. Electrolyte Imbalance and QT Prolongation
Problem 6. Chronic HBV Infection with Cirrhosis
Problem 7. Inflammatory Activity and Infection Surveillance
[MedRec]
[radiotherapy]
[immunochemotherapy]
2024-05-29 - enfortumab vedotin 30mg NS 100mL 1hr
2024-05-22 - enfortumab vedotin 30mg NS 100mL 1hr
2024-05-02 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + cisplatin 35mg/m2 50mg NS 500mL 3hr
2024-04-22 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min
2024-03-20 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + cisplatin 35mg/m2 50mg NS 500mL 3hr
2024-03-06 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + cisplatin 35mg/m2 50mg NS 500mL 3hr
2024-02-21 - gemcitabine 1000mg/m2 1000mg NS 100mL 30min + cisplatin 35mg/m2 50mg NS 500mL 3hr
2024-01-24 - gemcitabine 1000mg/m2 1000mg NS 100mL 30min + cisplatin 70mg/m2 80mg NS 500mL 3hr
2024-01-11 - gemcitabine 1000mg/m2 1400mg NS 100mL 30min + cisplatin 70mg/m2 80mg NS 500mL 3hr + furosemide 20mg
2022-07-27 - cisplatin 30mg/m2 30mg BI 1hr
2022-07-13 - mitomycin-C 30mg/m2 30mg BI 1hr
2022-07-06 - cisplatin 30mg/m2 30mg BI 1hr
2022-06-08 - cisplatin 30mg/m2 30mg BI 1hr
2022-06-01 - cisplatin 30mg/m2 30mg BI 1hr
2022-05-25 - cisplatin 30mg/m2 30mg BI 1hr
2022-05-18 - cisplatin 30mg/m2 30mg BI 1hr
2022-05-06 - mitomycin-C 30mg/m2 30mg BI 1hr
2021-09-15 - mitomycin-C 30mg/m2 30mg BI 1hr
2021-09-08 - cisplatin 30mg/m2 30mg BI 1hr
2021-09-01 - cisplatin 30mg/m2 30mg BI 1hr
2021-08-25 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2021-08-18 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2021-08-11 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2021-08-06 - mitomycin-C 30mg/m2 30mg BI 1hr
2021-04-07 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2021-03-31 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2021-03-24 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2021-03-17 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2021-03-10 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2021-03-03 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2021-02-24 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2021-02-05 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2020-10-31 - cisplatin 30mg/m2 30mg BI 1hr
2020-10-07 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2020-09-30 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2020-09-23 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2020-09-16 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2020-09-09 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2020-09-02 - BCG 2*10^8CFU/vial 1vial NS 50mL BI 1hr
2020-07-22 - gemcitabine 1000mg/m2 1400mg NS 100mL 30min
2020-07-03 - gemcitabine 1000mg/m2 1400mg NS 100mL 30min + cisplatin 70mg/m2 100mg NS 500mL 3hr + furosemide 20mg
2020-05-06 - gemcitabine 1000mg/m2 1400mg NS 100mL 30min
2020-04-29 - gemcitabine 1000mg/m2 1400mg NS 100mL 30min + cisplatin 70mg/m2 100mg NS 500mL 3hr + furosemide 20mg
2020-03-25 - gemcitabine 1000mg/m2 1400mg NS 100mL 30min
2020-03-04 - gemcitabine 1000mg/m2 1400mg NS 100mL 30min
2020-02-21 - gemcitabine 1000mg/m2 1400mg NS 100mL 30min + cisplatin 70mg/m2 100mg NS 500mL 3hr + furosemide 20mg
2020-02-12 - gemcitabine 1000mg/m2 1400mg NS 100mL 30min
2020-01-22 - gemcitabine 1000mg/m2 1400mg NS 100mL 30min
2020-01-08 - gemcitabine 1000mg/m2 1400mg NS 100mL 30min
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
[Dulcolax (bisacodyl 5mg) tube feeding]
Due to the enteric coating of Dulcolax (bisacodyl 5mg) tablets, splitting or crushing them is not recommended. As an alternative, Bisadyl (bisacodyl 10mg) suppositories, which contain the same active ingredient, can be utilized. Currently, the patient is taking Through (sennoside 12mg) twice daily at bedtime and Bisadyl (bisacodyl 10mg) suppositories 2 units rectally as needed once daily.
[Problem List]
Problem 1. Esophageal Squamous Cell Carcinoma (Post-CCRT, ongoing monitoring)
Problem 2. Hematological Status (Post-CCRT myelosuppression and recovery) (below not posted)
Problem 3. Renal and Hepatic Function (Monitoring cisplatin-related toxicity)
Problem 4. Electrolyte and Metabolic Status (Post-treatment stability)
Problem 5. Nutritional Status and Gastrointestinal Support (During recovery phase)
Problem 6. Auditory Status (Baseline hearing assessment)
Problem 7. Severe Anorexia and Weight Loss (Loss of appetite - Grade 3) (posted)
The patient is a 62-year-old male with esophageal squamous cell carcinoma (ESCC), cT3N2M0, Stage III (Pathology 2025-02-12; EGD 2025-02-12; CT 2025-02-22; EUS 2025-02-26), currently arranged concurrent chemoradiotherapy (CCRT) with cisplatin and fluorouracil (2025-03-17). No distant metastasis was identified in PET (2025-02-24). The tumor is locally advanced, involving lymph nodes (subcarinal, paraesophageal region) but remains resectable possibility.
Additional relevant conditions include:
- Atrophic gastritis with gastric polyps (EUS 2025-02-26)
- Mild to moderate emphysematous changes in both lungs (CT
2025-02-22)
- Arachnoid cyst (62mm) in the right retro-cerebellar region (MRI
2025-03-01)
- Hyperplastic colorectal polyps (Pathology 2025-02-26)
- Degenerative joint disease with increased bone scan uptake in multiple
sites (Bone scan 2025-02-27)
- Mild anemia (HGB 13.4 g/dL) and stable renal function (eGFR 127.75
mL/min/1.73m²) (Labs 2025-03-17)
- Good nutritional status but with increased caloric and protein
requirements (Nutrition 2025-03-17)
Problem 1. Esophageal Squamous Cell Carcinoma (cT3N2M0, Stage III, arranged CCRT)
Problem 2. Nutritional Status (Increased Caloric and Protein Requirement During CCRT)
Problem 3. Hematologic and Organ Function Monitoring (During Chemoradiation Therapy)
Problem 4. Pulmonary Function (Mild Emphysematous Change, Smoking History)
Problem 5. Skeletal and Neurologic Considerations (Bone Scan Uptake, Arachnoid Cyst) (not posted)
Overall Plan
[exam finding]
[MedRec]
[consultation]
[Subjective]
chest pain with dyspnea on 2025-03-26
- presented to ER due to new-onset chest pain without radiation
- described onset around 05:00, no associated back pain (POMR
2025-03-27)
- denied further episodes of chest pain or dyspnea post-intervention
(POMR 2025-03-28)
- on 2025-04-16, during pharmacist contact, the patient reported no
current respiratory discomfort, noted that urine had changed from yellow
to clear, and stated that he could walk briskly without problems
history of cardiovascular and metabolic diseases
- known hypertension, diabetes mellitus, mixed hyperlipidemia
- regular follow-up at NTU hospital (POMR 2025-03-27)
post-discharge condition
- clinically stable post-PCI (SOAP 2025-03-31)
- no recurrent chest discomfort reported
- instructed to monitor symptoms and follow up in outpatient
department
- pharmacist reminded the patient on 2025-04-16 to seek medical
attention promptly if any signs of bleeding occur due to use of dual
antiplatelet therapy
[Objective]
acute coronary syndrome and cardiac markers
- markedly elevated hs-Troponin I: 12.4 → 199.3 → 497.4 → 1284.6 pg/mL
(Labs 2025-03-26 to 2025-03-28)
- CKMB: 1.4 → 3.3 → 4.5 → 8.3 ng/mL, CK: within normal range (Labs
2025-03-26 to 2025-03-28)
- 2D echo showed LVEF 58% with no RWMA, mild valvular regurgitations
(Echo 2025-03-26)
lipid and glucose profiles
- LDL-C 66 mg/dL, HDL-C 22 mg/dL, TG 238 mg/dL, total cholesterol 113
mg/dL (Labs 2025-03-28)
- HbA1c 7.3% and serum glucose 227 mg/dL (Labs 2025-03-26 to
2025-03-28)
renal and hepatic function
- creatinine 1.09 mg/dL, eGFR 72.39 mL/min/1.73m² (Labs
2025-03-26)
- ALT 35 U/L (Labs 2025-03-26)
coagulation status
- PT 10.8 sec, INR 1.02, APTT 40.3 sec (Labs 2025-03-27)
current medications post-NSTEMI and PCI
- dual antiplatelet: Brilinta (ticagrelor), Bokey (aspirin)
- statin: Crestor (rosuvastatin)
- antihypertensives: Diovan FC (valsartan), Norvasc (amlodipine),
Carvedilol Hexal (carvedilol), Apolin (hydralazine PRN)
- antihyperglycemics: Forxiga (dapagliflozin), Uformin (metformin),
Xigduo XR (dapagliflozin/metformin)
- GI protection: Nexium (esomeprazole)
[Assessment]
post-NSTEMI management with PCI and adequate secondary prevention
initiated
- evidence of myocardial injury supported by serial hs-Troponin I and
CKMB elevation (Labs 2025-03-26 to 2025-03-28)
- PCI to LM-LAD was successful without complications (POMR
2025-03-27)
- LVEF preserved (58%) with no RWMA, mild valvular lesions (Echo
2025-03-26)
lipid and glycemic control suboptimal
- despite LDL-C <70 mg/dL, HDL-C is markedly reduced and TG elevated
(Labs 2025-03-28)
- HbA1c 7.3% indicates suboptimal glycemic control (Labs
2025-03-28)
- statin and SGLT2 inhibitor combination may benefit both CV risk and DM
control
COPD with obstructive pattern confirmed
- mild obstructive ventilatory impairment with bronchodilator response
(LFT 2025-03-06)
- current medication list does not include any inhaler for COPD
management
potential drug-related risks
- Brilinta (ticagrelor) + Bokey (aspirin): bleeding risk, monitor for
signs of GI bleeding or bruising
- hypotension risk due to multiple antihypertensives (Diovan FC,
Norvasc, carvedilol, hydralazine PRN)
- bradycardia risk from carvedilol (hold if HR < 60)
[Plan / Recommendation]
optimize cardiovascular protection and medication monitoring
- maintain dual antiplatelet therapy for at least 12 months post-PCI if
no contraindications
- assess bleeding risk regularly
- continue Crestor (rosuvastatin 10mg), consider uptitration if TG
remains elevated
- monitor HR and BP for carvedilol titration; consider reducing dose if
HR < 60 bpm
refine metabolic management
- continue Xigduo XR (dapagliflozin/metformin) for glycemic and CV
benefit
- monitor renal function periodically
- review dietary adherence and physical activity to support HbA1c and TG
reduction
- reinforce lifestyle modification as emphasized in SOAP 2025-03-31
address COPD care
- encourage smoking cessation
patient education and follow-up
- reinforce understanding of dual antiplatelet therapy and the
importance of adherence
- educate patient to monitor for and report bleeding signs, especially
due to dual therapy (reminded again during 2025-04-16 visit)
[MedRec]
[chemotherapy]
[exam finding]
[MedRec]
[Subjective]
Heart failure and fluid overload
- Dyspnea improved following diuretic and rate control therapy
- No current exertional dyspnea reported post-discharge (POMR
2025-04-11)
- Patient adheres well to medications and inquired about the impact of
shift work on heart health (clinic note 2025-04-16)
- Advised to maintain consistent sleep-wake cycles despite night
shifts
- No orthopnea, PND, chest pain, or fever reported
Atrial fibrillation and stroke prevention
- Paroxysmal Af with prior rapid ventricular response (ECG
2025-04-05)
- Converted to sinus rhythm on 2025-04-09; stable rhythm maintained
thereafter
- Patient currently on short-term anticoagulation with apixaban
- No bleeding or adverse effects reported
Medication and self-care adherence
- Strong adherence reported (2025-04-16)
- Patient expressed concern about renal function
- Explained to be moderate CKD; advised to maintain hydration and avoid
NSAIDs
- Patient also inquired about possible benefit from SGLT2 inhibitor; was
advised to discuss with cardiologist at follow-up
[Objective]
Renal function and electrolytes
- Creatinine improved to 0.99 mg/dL on 2025-04-09 from 1.54 mg/dL
(2025-04-05); eGFR 61.45 mL/min/1.73m²
- BUN still elevated at 30 mg/dL (2025-04-09), suggesting ongoing renal
involvement
- Normonatremia and potassium borderline low (K 3.6 mmol/L)
Heart function and imaging
- NT-proBNP significantly elevated: 9405.2 pg/mL (2025-04-05)
- 2D Echo (2025-04-08): Preserved LVEF (56.6%), concentric LVH, mild MR,
moderate TR, IVC and atrial dilatation
Hematology
- Microcytic anemia with HGB 9.5–10.9 g/dL, MCV ~67 fL, RDW 17.2%
- Iron deficiency parameters: Fe 19 ug/dL, TIBC 275 ug/dL, ferritin 70.2
ng/mL
- Known history of thalassemia (clinic note 2025-04-16)
Other labs
- HbA1c 6.1% (2025-04-09): acceptable glycemic control
- Lipid profile (2025-04-09): TC 98, LDL 41, HDL 46 mg/dL – well
controlled
Discharge medications (as of 2025-04-11)
- Cordarone (amiodarone) 200 mg QD
- Eliquis (apixaban) 5 mg BID
- Exforge FC (amlodipine + valsartan) 1 tab QD
- Nakasser SR (diltiazem) 120 mg QD
- Spiron (spironolactone) 25 mg BID
- Uretropic (furosemide) 40 mg QD
[Assessment]
Heart failure with preserved EF (HFpEF)
- Well-controlled clinically post-discharge
- Continued risk of volume overload and elevated filling pressures
(NT-proBNP 9405.2 pg/mL on 2025-04-05)
- Shift work may be a contributing factor; patient counseled on
maintaining stable circadian rhythm
Paroxysmal atrial fibrillation
- Successfully converted to sinus rhythm on 2025-04-09
- Appropriate short-term anticoagulation with apixaban (CHA₂DS₂-VASc =
4)
- Amiodarone planned for short-term rhythm stabilization
Chronic kidney disease (stage 3b)
- Improved creatinine on 2025-04-09 (0.99 mg/dL), eGFR 61.45
mL/min/1.73m²
- Ongoing renal vulnerability with elevated BUN and prior lower eGFR
(36.90 mL/min/1.73m² on 2025-04-05)
- Patient advised to maintain hydration and avoid chronic NSAID use
Thalassemia trait with coexisting iron deficiency anemia
- Microcytic anemia likely multifactorial: iron deficiency (Fe 19 µg/dL)
and thalassemia (clinic note 2025-04-16)
- Ferritin borderline; inflammation or chronic disease may co-exist
Diabetes mellitus
- Stable glycemic control under outpatient management (HbA1c 6.1%)
[Plan / Recommendation]
Heart failure and volume status
- Continue diuretics (Uretropic, Spiron) and ARB-based antihypertensive
(Exforge FC)
- Reinforce daily weight monitoring and fluid intake targets
- Encourage stable sleep schedule despite night shifts to support
autonomic balance
Atrial fibrillation
- Maintain apixaban for stroke prevention, reassess duration at
follow-up
- Continue amiodarone short-term only; monitor thyroid/liver function if
prolonged
- Consider long-term rhythm strategy based on recurrence and
symptoms
Renal support
- Maintain good hydration
- Avoid NSAIDs unless strictly indicated
- Monitor renal function (eGFR, creatinine, electrolytes)
periodically
- Strongly consider adding an SGLT2 inhibitor (e.g., dapagliflozin or
empagliflozin) to benefit both HF and CKD if not contraindicated; to be
discussed with cardiologist
Anemia and thalassemia
- Recommend trial of oral iron supplementation
- If anemia persists, consider hemoglobin electrophoresis follow-up for
more precise thalassemia genotyping
- Avoid excessive iron loading due to thalassemia component
Metabolic and cardiovascular risk control
- Continue statins and antihypertensive therapy
- Periodic lipid panel and HbA1c checks
- Encourage physical activity and dietary salt restriction
[MedRec]
2025-03-20 ~ 2025-04-15 POMR Hemato-Oncology Liu YiSheng
2025-02-11 ~ 2025-02-15 POMR Gastroenterology Chen ZhiXiang
2025-01-24 ~ 2025-01-27 POMR Gastroenterology Chen ZhiXiang
[immunochemotherapy]
[exam finding]
[MedRec]
[consultation]
2025-03-20 Dermatology
2025-03-19 Rehabilitation
2025-03-16 Cardiology
[Subjective]
cardiovascular events and post-PCI care
- 60-year-old male with dermatomyositis under control, presented with
chest pain and dyspnea since 2025-03-08
- visited YunLin Christian Hospital on 2025-03-13 with suspected NSTEMI;
started on dual antiplatelet therapy
- transferred to this facility with worsening dyspnea on 2025-03-16;
diagnosed with NSTEMI, cardiogenic shock, and pulmonary edema
- PCI on 2025-03-17 with stent placement in LAD, balloon angioplasty for
D1 and LCX with thrombus aspiration
- post-procedure hypotension managed with norepinephrine and
atropine
- dizziness and hypotension persisted; improved with midodrine and
corticosteroid
- pharmacist visited patient on 2025-04-16; patient reported no problems
with medication use and said the herpes simplex on buttock had mostly
healed
gastrointestinal protection and herpes simplex
- Nexium (esomeprazole) started for ulcer prophylaxis
- Buttock vesicular rash (2025-03-20), treated as herpes simplex with
topical acyclovir
[Objective]
vital signs and symptoms
- hypotension (BP 109/60 mmHg on 2025-03-16), cold sweating,
dyspnea
- post-PCI hypotension requiring vasopressor and midodrine support
labs and imaging
- elevated hs-Troponin I 3300.9 pg/mL (2025-03-16), NT-proBNP 4585.7
pg/mL
- echocardiography (2025-03-18): mildly impaired LV systolic function,
EF 46.6% (2D), regional wall motion abnormality
- ECG (2025-03-18): anteroseptal infarct, prolonged QT
- CBC (2025-03-21): HGB 11.1 g/dL, PLT 381 ×10^3/uL, WBC 6.10
×10^3/uL
- cortisol 8.33 ug/dL (2025-03-21), relatively low
- cholesterol: low HDL-C (22 mg/dL), normal LDL-C (100 mg/dL) on
2025-03-17
- iron studies (2025-03-21): Fe 74 ug/dL, TIBC 275 ug/dL, UIBC 201
ug/dL
current medications (2025-03-27 SOAP note)
- Bokey (aspirin 100 mg QD)
- Brilinta (ticagrelor 90 mg BID)
- Crestor (rosuvastatin 10 mg QD)
- Midorine (midodrine 2.5 mg PRN QD if SBP <100)
- Mexium (esomeprazole 40 mg QDAC)
- cortisone acetate 25 mg BID
[Assessment]
post-NSTEMI dual antiplatelet therapy
- appropriate DAPT with aspirin and ticagrelor post-stenting
- gastric protection with esomeprazole reduces risk of GI bleeding
lipid management
- Crestor (rosuvastatin) indicated for secondary prevention
post-ACS
- however, HDL-C remains low (22 mg/dL), additional cardiovascular risk
remains
orthostatic hypotension
- resolved with midodrine and corticosteroid; may reflect adrenal
insufficiency or autonomic dysregulation
- cortisol level borderline low (8.33 ug/dL), justifying corticosteroid
replacement
cardiogenic shock and post-PCI recovery
- improved with vasopressor support and resolution of pulmonary
edema
- current LVEF mildly reduced, but stable
herpes simplex management
- topical acyclovir appropriate for localized HSV infection
- now mostly healed according to patient report on 2025-04-16
medication adherence
- no adverse drug reactions or usage problems reported by patient during
pharmacist visit on 2025-04-16
[Plan / Recommendation]
post-ACS antiplatelet therapy
- continue Bokey (aspirin) 100 mg QD and Brilinta (ticagrelor) 90 mg BID
for at least 12 months unless bleeding occurs
- reinforce adherence and bleeding precautions
lipid management
- continue Crestor (rosuvastatin) 10 mg QD
- consider rechecking lipid profile in 4–8 weeks to assess
response
- if HDL-C remains low and LDL goal not met, consider dose escalation or
add-on therapy (e.g., ezetimibe)
hypotension and adrenal support
- maintain cortisone acetate 25 mg BID as current dose seems to
alleviate hypotension
- consider ACTH stimulation test if long-term corticosteroid use is
expected
- PRN midodrine may be tapered off as BP stabilizes
gastrointestinal protection
- continue Mexium (esomeprazole) 40 mg QDAC with DAPT
- monitor for long-term PPI-related effects if used >8 weeks
infection management
- continue topical acyclovir if any residual lesion persists
- no further intervention needed unless recurrence
medication safety monitoring
- patient showed good adherence and tolerance to current regimen per
pharmacist evaluation on 2025-04-16
- continue patient education and reinforce medication understanding
[lab data]
2025-04-07 BM chromosome analysis CYTOGENETICS LABORATORY REPORT - Chromosome Analysis: - Tissue Examined: Bone marrow - Staining Method: G-Banding - Colony number: NA - Bands level: 500 - Chromosome Counts: 45-(3)、46-(17)、47-()、Other-() Total-(20) - Karyotype: 46,XY[17] - Interpretation: - Analysis of this bone marrow sample shows a male having 46,XY[17] karyotype. There was no significant clonal chromosomal abnormality detected. Additionally, out of 20 cells analyzed, two cells with [45,X,-Y] and another cell with [45,XY,-21] were observed. No clinical significance can be ascribed to these non-clonal findings at the present time. - Note: - ROUTINE BANDED LEVEL DOES NOT RULE OUT REARRANGEMENT ONLY SEEN AT HIGHER LEVELS OF RESOLUTIONS.
2025-03-10 HBsAg Nonreactive
2025-03-10 HBsAg Value 0.32 S/CO
2025-03-10 Anti-HCV Nonreactive
2025-03-10 Anti-HCV Value 0.07 S/CO
2025-03-10 Anti-HBc Reactive
2025-03-10 Anti-HBc Value 6.24 S/CO
2025-03-07 FKLC 395.12 mg/L
2025-03-07 FLLC 17.80 mg/L
2025-03-07 FK/FL ratio 22.20 ratio
2025-03-06 Protein, total 9.1 g/dL
2025-03-06 Albumin 24.3 %
2025-03-06 Alpha-1 4.3 %
2025-03-06 Alpha-2 9.7 %
2025-03-06 Beta 18.5 %
2025-03-06 Gamma 43.2 %
2025-03-06 M-peak Positive
2025-03-06 A/G Ratio 0.30
2025-03-06 IgG/A/M Kappa/Lambda IgA + Kappa chain
2025-03-05 IgE <2.00 IU/mL
2025-03-05 ANA Negative
2025-03-04 IgG (blood) 601 mg/dL
2025-03-04 IgA 4805 mg/dL
2025-03-04 IgM 56.0 mg/dL
2025-03-04 C3 120.9 mg/dL
2025-03-04 C4 73.4 mg/dL
[exam finding]
[chemotherapy]
[lab data]
2025-04-12 ACTH 99.0 pg/mL
2025-04-12 Cortisol 33.17 ug/dL
[exam finding]
[consultation]
[MedRec]
[chemotherapy]
The 66-year-old female patient has a known history of myelodysplastic syndrome with refractory anemia with excess blasts (RAEB), which appears to have evolved into acute myeloid leukemia (AML) around 2025-02-24 as evidenced by a transient blast surge to 38.0% (CBC 2025-02-24). Although this blast count subsequently decreased, it surged again to 26.9% on 2025-04-14, confirming AML transformation (WHO criteria: blasts ≥20%). Her clinical condition is further complicated by progressive pancytopenia, severe hypoalbuminemia, hyponatremia, renal over-clearance (likely due to cachexia), high inflammatory markers (CRP up to 23.7 mg/dL on 2025-04-11), suspected enterocolitis (CT 2025-02-24), pruritic skin lesions due to scabies, and possible relative adrenal hyperfunction (ACTH 99.0 pg/mL and cortisol 33.17 µg/dL on 2025-04-12). She remains functionally ECOG PS 2 and afebrile as of 2025-04-15 morning (VS 2025-04-15 08:58).
Problem 1. AML Transformation from MDS
Problem 2. Pancytopenia with Severe Thrombocytopenia and Anemia
Problem 3. Hyponatremia with Hypoalbuminemia and Cachexia
Problem 4. Possible Relative Hypercortisolism
Problem 5. Infectious Inflammation and Scabies
[lab data]
2024-12-17 HSV 1+2 IgM Negative
2024-12-17 HSV 1+2 IgM Value <0.50 Index
2024-12-16 AMA Negative
2024-12-16 ASMA Negative
2024-12-16 FLT3-D835 (BM) Undetectable
2024-12-14 ANCA IU/ml
2024-12-14 PR3 Negative IU/ml
2024-12-14 PR3 Value <0.6 IU/ml
2024-12-14 MPO Negative
2024-12-14 MPO Value 0.2 IU/ml
2024-12-14 EB VCA IgM Negative Index
2024-12-14 EB VCA IgM Value 0.7 Index
2024-12-13 IgG (blood) 1383 mg/dL
2024-12-13 Anti-HAV IgM Nonreactive
2024-12-13 Anti-HAV IgM Value 0.30 S/CO
2024-12-13 CMV IgM Nonreactive
2024-12-13 CMV IgM Value 0.22 Index
2024-12-05 FLT3/ITD (BM) Undetectable
2024-12-05 NPM1 (qual) (BM) Undetectable
2024-12-05 JAK2 mutation (quan) 0.00 %
2024-12-05 BCR／abl (qual) Undetectable
2024-12-02 MPO stain Positive(2+)
2024-12-02 CAE stain Positive
2024-12-02 ANAE stain Positive
2024-11-29 LAP Stain 84 score
2024-11-29 HBsAg Nonreactive
2024-11-29 HBsAg (Value) 0.32 S/CO
2024-11-29 Anti-HBc Reactive
2024-11-29 Anti-HBc-Value 4.13 S/CO
2024-11-29 Anti-HCV Nonreactive
2024-11-29 Anti-HCV Value 0.19 S/CO
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
2025-04-10 - cytarabine 30mg/m2 54mg SC D1-7 (low dose Ara-C with oral Venclexta (venetoclax) 100mg QDCC)
2025-02-27 - daunorubicin 45mg/m2 77mg NS 100mL 30min D1-2 + cytarabine 100mg/m2 172mg NS 500mL 24hr D1-5
2025-01-10 - daunorubicin 45mg/m2 80mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 179mg NS 500mL 24hr D1-7
2024-12-06 - daunorubicin 45mg/m2 62mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 92mg NS 500mL 24hr D1-7 (TBI 2.61 => Daunoblastina 75%, Cytosar 50%)
The patient is a 65-year-old man with AML undergoing multiple cycles of chemotherapy (including standard 7+3 and low-dose cytarabine regimens). Despite transient reductions in blast counts and initial marrow hypocellularity, refractory/residual disease persists. His clinical course is complicated by persistent cytopenias (especially thrombocytopenia), intermittent febrile episodes with elevated inflammatory markers, progressive hepatocellular enzyme elevations, and electrolyte disturbances. The latest marrow biopsy (2025-03-20) suggests residual AML, and CBC trends as of 2025-04-14 continue to show pancytopenia with ANC < 500, Hgb ~8.0, and PLT < 30×10³/uL. He also developed anal abscess (2025-03-18 pathology) and hepatotoxicity possibly related to chemotherapy.
Problem 1. Persistent Cytopenia and Residual AML
Problem 2. Febrile Episodes with Infection Risk
Problem 3. Progressive Hepatotoxicity
Problem 4. Hypokalemia
Problem 5. Renal Function Fluctuation
Neutropenia Evaluation
Evaluation of Current Treatment Modalities
Assessment for Treatment Effects
Recommendations
Patient Summary
Problem 1: Acute Myeloid Leukemia (AML)
Problem 2: Cardiac Abnormalities
Problem 3: Chronic Viral Hepatitis B
Problem 4: Renal Dysfunction and Tumor Lysis Risk
[exam finding]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
[exam finding]
[MedRec]
[Subjective]
chest pain and cardiovascular symptoms
- recent STEMI episode on 2025-03-18
- presented with right chest pain at 4:00 AM
- ECG showed ST elevation at anterior wall
- hs-TnI elevated to 52.0 pg/mL
- admitted for catheterization and intervention
- received DAPT and PCI with POBA + DCB + BMS
past cardiovascular history
- STEMI in 2018, s/p LAD BMS placement
- history of CAD with single vessel disease
- known HFrEF with reduced EF post-MI
- latest LVEF 37.9% (2025-03-18)
- symptoms improved post-PCI and rehab initiation
chronic comorbidities
- essential hypertension
- hyperlipidemia
- idiopathic gout
- GERD without esophagitis
- former smoker (decades of smoking)
[Objective]
vital signs and labs
- BP 186/114 mmHg on 2025-03-18 (at ER)
- K 3.7 mmol/L, Na 141 mmol/L, Cr 1.20 mg/dL, eGFR 69.59
(2025-03-21)
- LDL 52 mg/dL, HDL 35 mg/dL, TG 107 mg/dL, total cholesterol 97
mg/dL
- HbA1c 5.6% (2025-03-21), glucose (AC) 92 mg/dL
- CKMB peaked at 99.2 ng/mL, CK 871 U/L (2025-03-19)
cardiac diagnostics
- ECG: T wave abnormalities, infarct patterns (anteroseptal, septal,
inferior)
- Echo (2025-03-18): LVEF 37.9%, septal/anterior wall akinesis, grade 1
diastolic dysfunction
- Cardiac catheterization (2025-03-18): 1VD (m-LAD instent total
occlusion), s/p PCI with BMS + DCB
medication list
- DAPT: Bokey (aspirin), Brilinta (ticagrelor)
- HF: Carvedilol Hexal, Blopress (candesartan), Jardiance
(empagliflozin), Spiron
- others: Crestor (rosuvastatin), Euricon (benzbromarone), Nexium
(esomeprazole), Nitrostat PRN
- anticoagulation: enoxaparin x 2 days (post-PCI)
[Assessment]
post-STEMI management
- patient adherent to DAPT (aspirin + ticagrelor), post-MI PCI (POBA +
DCB + BMS)
- stabilized with resolution of chest discomfort and hemodynamic
improvement
- education and rehab initiated early with favorable response
heart failure management (HFrEF, NYHA II)
- on appropriate agents: beta-blocker, ARB, MRA, SGLT2 inhibitor
- EF improved from previous 44.8% (M-mode) to 37.9% (Simpson)
post-infarct
- room for diuretic optimization if volume overload occurs
lipid and CV risk
- on Crestor (rosuvastatin 10mg), achieved LDL 52 mg/dL
- HDL remains low (35 mg/dL), room for lifestyle counseling
- smoking cessation discussed
comorbid condition control
- gout managed with Euricon
- GERD addressed with Nexium
- BP still uncontrolled on admission, but appropriate antihypertensives
restarted
[Plan / Recommendation]
optimize cardiovascular pharmacotherapy
- continue DAPT for minimum 12 months post-PCI
- reassess bleeding risk vs ischemic benefit at 3, 6, and 12
months
- continue HF meds (carvedilol, candesartan, spironolactone,
empagliflozin)
- monitor for hypotension, hyperkalemia, and renal function
- consider titration of ARB or beta-blocker as tolerated
lipid management
- maintain rosuvastatin; LDL goal achieved
- consider targeting non-HDL-C and apoB if available
- emphasize diet and physical activity to raise HDL
gout and uric acid
- continue Euricon; uric acid within normal range
- monitor for renal function and urate fluctuations
antiplatelet and anticoagulant use
- ensure Brilinta adherence, monitor for bleeding
- enoxaparin discontinued appropriately after 2 days
BP and metabolic monitoring
- monitor BP control and reintroduce dose titration if persistent
hypertension
- glucose and HbA1c are at goal; no antidiabetic agents needed beyond
empagliflozin
GI protection
- consider tapering off Nexium after DAPT period if no GI symptoms
patient education and rehab
- reinforce smoking cessation
- encourage cardiac rehab participation
- monitor for symptoms of angina, dyspnea, or volume overload
[exam finding]
[exam finding]
[MedRec]
[surgical operation]
[Subjective]
medication use and adherence - patient currently on post-op medications with known indication - Tramacet used for pain control post-amputation - Xarelto FC (rivaroxaban 15mg) used for thromboembolism prevention post-EKOS/PTA - no report of nonadherence or ADR - no bleeding, dizziness, or nausea reported - patient status stable - BP 138/64 mmHg, HR 79 bpm - no active signs of infection or thrombosis - wound care ongoing, stable post-AK amputation - pain improving - dosage of Tramacet tapered from Q6H to Q12H
CV risk factors and medication control - history of hypertension - currently on Norvasc (amlodipine 5mg QD) and Concor (bisoprolol 5mg 0.5# QD) - no diabetes, no reported hyperlipidemia - no smoking or alcohol use noted
procedural and vascular history - acute limb ischemia (2025-03) s/p EKOS thrombolysis and Urokinase - post left above-knee amputation - currently has residual right PAOD and possible thoracic aortic pathology under evaluation
[Objective]
antithrombotic therapy - Xarelto FC (rivaroxaban 15mg) QDCC - correct dose for peripheral arterial disease with high thrombotic risk - no concurrent aspirin noted in recent prescription - coagulation profile stable previously (PT/INR/APTT within range) - no evidence of active bleeding
CV agents - Concor (bisoprolol 0.5# QD), Norvasc (5mg QD) - BP well controlled at 138/64 mmHg - HR 79 bpm, regular rhythm
pain management - Tramacet 1# Q12H - appropriate tapering for post-op control - no new reports of opioid-related side effects
labs and monitoring - potassium 2.8 mmol/L (2025-03-24): persistent mild hypokalemia - renal function stable: Cr 0.66, eGFR 126.82 (2025-03-24) - Hgb stable ~9.8 g/dL, platelets 215 x10³/uL - CRP decreasing trend (2.0 mg/dL on 2025-03-24 vs 8.4 earlier) - no evidence of liver or renal dysfunction
[Assessment]
anticoagulation - Xarelto 15mg QDCC appropriate for secondary prevention after PTA and acute limb ischemia - aspirin is discontinued intentionally by our cardiologist, tapering from dual antithrombotic therapy to NOAC monotherapy - no current bleeding or clotting concern
pain control - pain improving; Tramacet tapering is appropriate - monitor for sedation or constipation as use continues
CV control - blood pressure and heart rate within target - dual-agent antihypertensive regimen appropriate - no statin use noted despite significant atherosclerotic burden
electrolyte imbalance - persistent mild hypokalemia (K 2.8 mmol/L, 2025-03-24) not yet addressed pharmacologically - may predispose to arrhythmia or muscle weakness
nutritional and anemia support - anemia (Hgb ~9.8) likely chronic and post-op related - no active replacement or iron/ferritin monitoring noted - albumin was low during hospitalization (2.7–2.8 g/dL)
[Plan / Recommendation]
antithrombotic management - clarify whether aspirin was discontinued intentionally or omitted - consider low-dose aspirin addition if not contraindicated, especially given high-risk vasculopathy - continue rivaroxaban 15mg QDCC for at least 30–90 days post-intervention - reassess at vascular/cardiology follow-up
electrolyte correction - recommend potassium supplementation - check K level, KCl 600 mg (8 mEq) BID x 3–5 days if needed, then recheck electrolytes - counsel patient on high-potassium dietary sources
CV risk reduction - initiation of statin therapy (e.g., atorvastatin 20mg QD) should be discussed with doctor. - strong atherosclerotic background (aortic thrombus, iliac occlusion, PAOD)
pain and rehabilitation - continue Tramacet 1# Q12H PRN, assess daily pain scores - encourage transition to non-opioid agents as tolerated (e.g., acetaminophen monotherapy) - ensure rehab consult for post-AK amputation mobility plan
nutritional and anemia management - consider CBC + iron panel + reticulocyte count for anemia assessment - monitor serum albumin and prealbumin if wound healing remains suboptimal - consider oral iron (e.g., ferrous sulfate 325mg QD) if IDA confirmed
follow-up and education - reinforce medication adherence - monitor for bleeding (Xarelto), dizziness, fatigue, constipation - arrange chest CTA as planned by cardiology to reassess thoracic aortic status
[exam finding]
[MedRec]
2024-12-29 ~ 2025-01-24 POMR General and Gastrointestinal Surgery Chen YanZhi
2024-11-29 ~ 2024-12-06 POMR Gastroenterology Hong YuLong
2024-07-08 ~ 2024-07-12 POMR Infectious Disease Peng MingYe
2024-02-13 ~ 2024-02-17 POMR Cardiology Xie JianAn
2023-06-03 ~ 2023-06-07 POMR Integrative Medicine Cheng HengXiang
2023-04-19 ~ 2023-04-21 POMR General and Gastroenterological Surgery Wu ChaoQun
2021-12-12 ~ 2021-12-20 POMR Chest Medicine Lan ZhouJin
[surgical operation]
[immunochemotherapy]
[MedRec]
[surgical operation]
[exam finding] (not completed)
[MedRec]
2025-04-02 ~ 2025-04-07 POMR Hemato-Oncology Xia HeXiong
2025-03-26 SOAP Hemato-Oncology Xia HeXiong
2025-03-20 SOAP Cardiology Zhou XingHui
2025-03-16 ~ 2025-03-18 POMR General and Gastroenterological Surgery Zhang JianHui
2025-03-06 SOAP Hemato-Oncology Xia HeXiong
2025-03-06, 2025-02-13, 2025-01-16 SOAP Nephrology Peng QingXiu
2022-07-25 ~ 2022-07-27 POMR Nephrology Peng QingXiu
[surgical operation]
[chemotherapy]
[lab data]
2025-03-07 HBsAg (NM) Negative
2025-03-07 HBsAg Value (NM) 0.386
2025-03-07 Anti-HBc (NM) Positive
2025-03-07 Anti-HBc Value (NM) 0.008
2025-03-07 Anti-HCV (NM) Negative
2025-03-07 Anti-HCV Value (NM) 0.038
2025-03-07 CEA 5.92 ng/mL
2025-03-07 CA199 20.03 U/mL
[exam finding]
[MedRec]
[immunochemotherapy]
[exam finding]
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
The patient is a post-liver transplant recipient with rectal cancer status post CCRT and ongoing hemodialysis-dependent ESRD. He is receiving FOLFOX chemotherapy and immunosuppression with Prograf (tacrolimus). Over the last two months, the patient has experienced progressive anemia, persistent thrombocytopenia, and worsening renal function. Liver function remains biochemically stable, but there is a concern for subtherapeutic tacrolimus levels. The patient tolerates chemotherapy well without major GI or infectious complications.
Problem 1. Progressive Anemia
Problem 2. Renal Dysfunction (ESRD on Hemodialysis)
Problem 3. Liver Function & Tacrolimus Monitoring (Post-transplant liver)
Problem 4. Chemotherapy for Rectal Cancer
[Anemia]
The patient has recent evidence of anemia with a hemoglobin (Hgb) level of 6.8 g/dL on 2025-02-06, down from 9.5 g/dL on 2025-01-16, accompanied by macrocytosis (MCV 101.5 fL). This anemia occurs in the context of advanced malignancy, recent chemotherapy with FOLFOX (2025-02-07), chronic kidney disease requiring hemodialysis (HD), and a history of liver transplantation under Prograf (tacrolimus). Anemia management must consider underlying causes such as chemotherapy effects, CKD-related anemia, and potential deficiencies.
Step 1: Objective Findings
Step 2: Assessment
Step 3: Recommendations
[Patient Summary]
This is a 65-year-old male with a complex medical history including:
[Anemia Assessment]
Current Status:
Etiology:
Management Recommendations:
[Iron Status Assessment]
The lab results show iron levels and related parameters from 2024-09-14, which provide info for the patient’s iron status:
Iron Studies (2024-09-14):
Interpretation:
Conclusion:
Management Recommendations:
[Liver Function Test]
Evaluation of Liver Function and Trends in the Last 3 Months:
Key Liver Function Indicators:
Trend Analysis:
Conclusion:
[Comments on Tacrolimus Levels]
Observed Trends and Levels
Integration with the Current Context
[Transplanted Liver Function Assessment] (not posted)
Clinical Context
Laboratory Trends
Imaging Findings
Integration of Tacrolimus Levels
Synthesis
Next Steps
[exam finding]
[MedRec]
[consultation]
[Subjective]
patient status and progress - post-STEMI recovery - stabilized hemodynamics - extubated and ambulatory
[Objective]
current medications - DAPT: Bokey (aspirin 100 mg QD), Brilinta (ticagrelor 90 mg BID) - statin: Crestor (rosuvastatin 10 mg QD) - ezetimibe: Ezetrol (10 mg QD) - beta-blocker: Carvedilol Hexal 6.25 mg BID (hold if SBP < 100 or HR < 60) - PPI: Nexium (esomeprazole 40 mg QDAC) - SGLT2i + metformin: Xigduo XR (dapagliflozin 10 mg + metformin 1000 mg QD) - HBV: Vemlidy (tenofovir alafenamide 25 mg QD)
labs - lipid profile: LDL 167 mg/dL, HDL 32 mg/dL, TG 234 mg/dL, Cholesterol 238 mg/dL (2025-03-17) - HbA1c: 6.9% (2025-03-17) - LFT: ALT 21 U/L, AST 15 U/L (2025-03-16) - CK: 4218 U/L, CKMB: 201.3 ng/mL (2025-03-17) - renal: Cr 0.88 mg/dL, eGFR 98.66 mL/min/1.73m² (2025-03-16)
vitals and tolerance - HR remained above 60 bpm - weight loss noted (87 kg → 81 kg)
[Assessment]
post-MI medication regimen - guideline-concordant therapy for post-STEMI and multivessel CAD - includes DAPT, statin + ezetimibe, beta-blocker, PPI - effective antiplatelet therapy with no bleeding complications - possible hypotension from carvedilol needs monitoring, but currently managed - high-intensity statin + ezetimibe appropriately initiated due to high LDL - ongoing Vemlidy for chronic HBV appropriate with normalized ALT/AST - glycemic control adequate (HbA1c 6.9%) with SGLT2i + metformin
potential optimization - LDL remains above target (< 55 mg/dL for very high-risk patients) - TG borderline elevated, HDL low - beta-blocker dose low - renal and liver functions stable; no contraindication to current meds
[Plan / Recommendation]
lipid control optimization - reinforce adherence to statin + ezetimibe - consider increasing Crestor to 20 mg if tolerated and LDL remains > 55 mg/dL on follow-up
beta-blocker management - continue carvedilol 6.25 mg BID - maintain “hold if SBP < 100 or HR < 60” instruction - consider slow up-titration if patient tolerates and no orthostatic symptoms recur
antiplatelet therapy - continue Bokey + Brilinta for at least 12 months post-PCI - assess bleeding risk regularly
glucose and HBV management - continue Xigduo XR for glycemic and cardiorenal benefit - continue Vemlidy; monitor HBV DNA and ALT every 3–6 months
monitoring and follow-up - check lipid panel and CK in 6-8 weeks - reinforce patient education on orthostatic precautions and medication adherence - reassess renal and liver function periodically
This is a 47-year-old male with multiple comorbidities, including chronic hepatitis B virus (HBV) infection, metabolic dysfunction-associated steatotic liver disease (MASLD), type 2 diabetes mellitus, and dyslipidemia. He experienced a ST-segment elevation myocardial infarction (STEMI) on 2025-03-16 complicated by ventricular fibrillation (VF), in-hospital cardiac arrest (IHCA), and hypoxic respiratory failure, requiring cardiopulmonary resuscitation (CPR), defibrillation, intubation, and urgent percutaneous coronary intervention (PCI) for triple-vessel coronary artery disease (CAD). Post-PCI, he achieved hemodynamic stability and underwent step-down care and rehabilitation. He is on guideline-directed medical therapy (GDMT), including dual antiplatelet therapy (DAPT), statins, beta-blockers, and glucose/lipid-lowering agents.
Problem 1. Acute STEMI with Cardiogenic Shock and Post-Resuscitation Syndrome
Problem 2. Coronary Artery Disease, Triple Vessel Disease
Problem 3. Type 2 Diabetes Mellitus with Cardiovascular Complications
Problem 4. Chronic Hepatitis B with Flare and MASLD
Problem 5. Dyslipidemia
Problem 6. Post-Cardiac Arrest Neurologic and Functional Status
[exam finding]
[MedRec]
[Subjective]
Heart failure and fluid overload - dyspnea improved after NIPPV and IV diuretic therapy - patient reported no chest discomfort or breathing difficulty post-treatment (POMR 2025-03-28) - self-monitoring plan initiated - instructed to monitor urine output and body weight at home (POMR 2025-03-31)
Anticoagulation for atrial fibrillation - no bleeding reported - warfarin education provided - patient and family instructed on importance of compliance and monitoring INR
Chronic kidney disease and anemia - no complaint of dizziness or fatigue - anemia stable around Hgb 9.2–9.6 g/dL (Labs 2025-03-14 to 2025-03-28)
Psychosomatic and cognitive issues - known alcohol-induced amnestic disorder - currently maintained on Vit B1, memantine, and olanzapine (SOAP 2025-03-14) - no acute behavioral change reported
[Objective]
Heart failure and fluid overload - NT-proBNP markedly elevated at 17711.9 pg/mL (2025-03-19) - echocardiography showed LVEF 69.5%, MR/TR/AR/PR, LA/RA dilation (Echo 2025-03-19) - pulmonary edema improved on CXR (2025-03-28) - IV Lasix tapered to oral Uretropic (furosemide) 40mg PRN (POMR 2025-03-31)
Anticoagulation for atrial fibrillation - INR subtherapeutic: 1.04 (2025-03-28), 1.15 (2025-03-31) - warfarin titration from 2 mg → 2.5 mg → 3.5 mg (POMR 2025-03-31) - no signs of active bleeding
Chronic kidney disease and anemia - creatinine rising from 3.87 (2025-03-19) to 4.74 mg/dL (2025-03-28), eGFR 9.59 mL/min/1.73m² - metabolic acidosis (HCO₃⁻ 12.3–16.2 mmol/L) - anemia with Hgb 9.3 g/dL (2025-03-28) - on Mircera (epoetin beta) Q1M SC (SOAP 2025-01-24)
Thyroid function - TSH elevated at 6.182 µIU/mL, Free T4 0.73 ng/dL (2025-03-28) - not on any thyroid replacement
Infection / UTI - UTI confirmed by urinalysis (bacteria 3+, WBCs 30–49/HPF) (2025-03-19) - treated with Zinacef (cefuroxime) empirically
[Assessment]
Heart failure and fluid overload - acute decompensated HFpEF with adequate response to NIPPV, diuretics - ongoing PRN diuretic use appropriate - volume and electrolyte status need close monitoring - no signs of recurrent edema noted
Anticoagulation for atrial fibrillation - warfarin underdosed based on low INR - titration in progress with current dose 3.5 mg daily - CKD stage 5 complicates warfarin metabolism - higher INR fluctuation risk
Chronic kidney disease and anemia - renal function worsened; eGFR <10, approaching dialysis threshold - anemia likely multifactorial (CKD, inflammation), managed conservatively - iron stores suggest functional deficiency (Fe 18 µg/dL, ferritin 277 ng/mL)
Thyroid dysfunction - biochemical hypothyroidism - not currently treated - possible impact from amiodarone
Infection / UTI - recurrent UTI likely from diabetes and residual urinary glucose/protein - no systemic signs at discharge
[Plan / Recommendation]
Heart failure and fluid overload - continue Uretropic (furosemide) 40mg PRN if BW gain >2kg or edema develops - encourage daily weight monitoring - recommend re-evaluation echocardiogram in 3–6 months to monitor valvular burden
Anticoagulation for atrial fibrillation - continue Cofarin (warfarin) 3.5 mg daily - check INR every 3–5 days until stable - avoid drug interactions (e.g., NSAIDs, some antibiotics) - evaluate for pharmacist-driven anticoagulation service if INR control remains suboptimal
Chronic kidney disease and anemia - maintain current Mircera regimen - suggest adding IV iron if TSAT <20% (not yet measured) - recheck iron panel and reticulocyte count - monitor metabolic panel every 2 weeks
Thyroid dysfunction - repeat TSH and Free T4 in 4 weeks - may discuss to consider starting low-dose levothyroxine if TSH remains elevated or symptoms emerge - monitor for bradycardia or angina due to concurrent HF
Infection / UTI - monitor for recurrent symptoms - suggest urine culture and sensitivity for targeted therapy if recurrence - reinforce hygiene, hydration, and glucose control
Other - continue psychosomatic medications (e.g., Zyprexa Zydis (olanzapine), Witgen (memantine), Vit B1) as per Psychiatry - follow up CKD care, consider vascular access planning if symptoms or lab thresholds met
This is a 73-year-old woman with multiple chronic conditions, including heart failure with preserved ejection fraction (HFpEF), chronic kidney disease (CKD) stage 5, paroxysmal atrial fibrillation (AF), and long-standing hypertension and diabetes, complicated by alcohol-induced cognitive disorder. She was recently hospitalized (2025-03-19 to 2025-03-31) for acute pulmonary edema, managed with non-invasive ventilation, intravenous diuretics, and antiarrhythmics. Echocardiogram showed preserved LVEF (69.5%), dilated atria, valvular abnormalities, and atrial fibrillation (AF) (Echo 2025-03-19). Labs show progressively worsening renal function, persistent anemia, elevated TSH with low Free-T4 (suggestive of hypothyroidism), and multiple urinary tract infections (UTIs). There are emerging concerns for electrolyte imbalance, warfarin titration challenges, and malnutrition or underlying chronic inflammation.
Problem 1. Acute Decompensated Heart Failure with Preserved Ejection Fraction (HFpEF)
Problem 2. Paroxysmal Atrial Fibrillation with Subtherapeutic Anticoagulation
Problem 3. Chronic Kidney Disease (CKD) Stage 5
Problem 4. Anemia of Chronic Disease and CKD
Problem 5. Recurrent Urinary Tract Infections
Problem 6. Subclinical Hypothyroidism
[INR Range]
For this simulated patient with paroxysmal atrial fibrillation, heart failure with preserved ejection fraction (HFpEF), hypertension, type 2 diabetes mellitus, and age ≥75, the recommended target INR range is 2.0 to 3.0.
Rationale
Conclusion:
[exam finding]
[MedRec]
[consultation]
[Subjective]
Cardiovascular symptoms - chest discomfort improved after PCI - no current chest pain or pressure - no cold sweating or palpitations reported - orthopnea improved - patient previously reported dyspnea at rest - no current dyspnea on exertion - dizziness on 2025-03-16 - related to hypotension - resolved with midodrine and IV saline
Heart failure history - history of HFrEF, NYHA class IV upon admission - improved to NYHA class II by discharge - no recent orthopnea or edema reported
Diabetes control - no reported hypoglycemia or polyuria - appetite stable post-PCI
Adherence and side effects - no reported intolerance to medications - patient and family declined CABG and opted for PCI - understands need for long-term DAPT
[Objective]
Cardiovascular status - 2025-03-11 cardiac catheterization - LM 50%, LAD 79%, LCX 94%, RCA 75% - PCI with DES x3 to RCA, LAD, LCX - 2025-03-07 echocardiography - LVEF 39.7% (Simpson), global hypokinesia - moderate MR, dilated LA - 2025-03-17–03-13 CXR - resolved pulmonary edema - persistent bilateral pleural effusion - 2025-03-12 ECG: LVH, possible inferior infarct - NT-proBNP 10761.4 pg/mL on 2025-03-10
Renal function - creatinine ranged 1.40–1.60 mg/dL - eGFR 45–53 mL/min/1.73m²
Electrolytes and anemia - K 3.3–3.6 mmol/L - Hgb 10.5–11.0 g/dL, ferritin 164 ng/mL, Fe 28 µg/dL - TIBC 281, transferrin 233.8 mg/dL
Medications as of 2025-03-27 - Efient (prasugrel 3.75mg QD) - Bokey (aspirin 100mg QD) - Carvedilol 6.25mg 0.5# QD - Spironolactone 25mg QD - Forxiga (dapagliflozin 10mg QDAC) - Furosemide 40mg PRN - Nexium (esomeprazole 40mg QDAC) - Foliromin (ferrous sodium citrate 50mg QD) - Crestor (rosuvastatin 10mg QD)
[Assessment]
Coronary artery disease post-PCI - underwent successful PCI with DES to RCA, LAD, LCX - appropriate use of DAPT (prasugrel + aspirin) - no active ischemic symptoms post-discharge - patient at high ischemic risk due to LM and 3VD - surgical revascularization was declined - optimal medical therapy is essential
Heart failure with reduced EF (HFrEF) - appropriate guideline-directed medications: beta-blocker, MRA, SGLT2i - ACEI/ARB/ARNI not included in regimen - unclear if omitted due to prior hypotension or renal risk - NYHA class improved from IV to II - good response to IV diuretics and isoket
Chronic kidney disease - CKD stage 3b likely due to hypertensive/ischemic origin - renal function stable post-diuresis - cautious diuretic use and nephroprotective therapy appropriate
Anemia, likely chronic disease/iron-restricted - borderline microcytic anemia, iron profile suggestive of functional iron deficiency - appropriate oral iron started - no overt bleeding signs, but on DAPT
Diabetes mellitus - HbA1c 5.7% may reflect chronic control or transient drop due to illness - Forxiga offers both glycemic and cardiorenal benefits
Dyslipidemia - LDL 133 mg/dL not at target for secondary prevention (<70 mg/dL) - rosuvastatin 10mg is moderate-intensity
[Plan / Recommendation]
Coronary artery disease post-PCI - continue DAPT (prasugrel + aspirin) for ≥12 months - reassess bleeding risk at 3-month intervals - add PPI (Nexium) appropriate for gastroprotection
Heart failure with reduced EF (HFrEF) - initiate low-dose ACEI (e.g., ramipril 1.25mg QD) if BP and K+ allow - reassess after 1 week - continue carvedilol, spironolactone, Forxiga - educate patient on daily weight, salt/fluid restriction, signs of volume overload
Chronic kidney disease - continue Forxiga for cardiorenal benefit - avoid NSAIDs and nephrotoxic agents - reassess renal panel monthly - consider ACR for proteinuria monitoring
Anemia - continue oral iron (Foliromin) - check reticulocyte count, stool OB - monitor CBC every 2–4 weeks
Diabetes mellitus - continue Forxiga monotherapy - recheck HbA1c in 3 months - monitor for hypoglycemia, especially during poor appetite or infection
Dyslipidemia - consider uptitrating rosuvastatin to 20mg QD or adding ezetimibe - recheck lipid panel in 6–8 weeks
Rehabilitation and follow-up - encourage continued participation in cardiac rehab - ensure medication adherence and BP/HR self-monitoring - follow-up in cardiology within 1–2 weeks
The patient (69-year-old male with NSTEMI, HFrEF, CAD with LM+3VD, T2DM, HTN, and hyperlipidemia)
Problem 1. Coronary Artery Disease (LM + 3VD) post-NSTEMI and PCI
Problem 2. Heart Failure with Reduced EF (HFrEF), ischemic origin
Problem 3. Chronic Kidney Disease (likely Stage 3b)
Problem 4. Type 2 Diabetes Mellitus
Problem 5. Anemia
Problem 6. Hyperlipidemia
Problem 7. Post-MI Cardiopulmonary Rehabilitation
Potential Gaps / Additional Considerations
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
The patient is a 78-year-old female diagnosed with synchronous moderately differentiated adenocarcinomas of the cecum and hepatic flexure with liver metastasis (pT3(m)N0, if cM1, AJCC stage IVA) confirmed on 2024-11-28 pathology. Additional KRAS G12A mutation (RAS mutation report 2024-12-04) and persistent liver lesions including a suspected intraductal cholangiocarcinoma or IPNB (MRI 2024-12-25; EUS 2025-01-09) complicate disease management.
The patient underwent laparoscopic right hemicolectomy on 2024-11-28, followed by systemic chemotherapy with Avastin + FOLFIRI, adjusted to 75% dose due to age and frailty (sessions on 2025-02-07, 2025-03-07, 2025-03-31). Tumor markers including CEA and CA199 have rebounded post-chemotherapy, raising concern for progressive disease. Anemia persists, likely multifactorial (chronic disease, malignancy, prior iron deficiency).
Overall, the disease appears progressive despite systemic therapy. Liver lesions show necrosis and atypical cells on biopsy, but viable tumor remains in other locations, suggesting mixed treatment response.
Problem 1. Progressive Metastatic Colorectal Cancer with Liver Involvement
Problem 2. Chronic Normocytic Anemia (Likely Multifactorial)
Problem 3. Hepatic and Biliary System Involvement (IPNB/Cholangiocarcinoma?)
Problem 4. Renal Function Preservation Despite Chemotherapy (not posted)
[lab data]
[exam finding]
[MedRec]
[S – Subjective]
Patient: 50-year-old female Chief Complaint: Seeking evaluation for weight management medication.
History of Present Illness (HPI):
Past Medical History (PMH):
Medications:
Lifestyle & Social History:
[O – Objective]
Anthropometrics:
Laboratory Data (2024-11-07):
[A – Assessment]
Obesity (BMI 25–30 kg/m²)
Hyperlipidemia (Persistent, untreated)
Previously noted elevated blood glucose, but last data point normal (Glucose 90 mg/dL, HbA1c 5.4%)
Pharmacologic Weight Management: Evaluation of Available Options. The patient is a candidate for GLP-1 receptor agonists (GLP-1 RAs) based on BMI and history of metabolic risk factors. Available options at this hospital include:
| Medication | Administration | Weight Loss Effect | Key Benefits | Common Side Effects | Notes |
|---|---|---|---|---|---|
| Semaglutide (Wegovy, Ozempic, Rybelsus) | Weekly (inj) or Daily (oral) | High | Once-weekly dosing, strong weight loss effect | GI upset, nausea, vomiting, delayed gastric emptying | Ozempic is for diabetes, Wegovy is for weight loss |
| Liraglutide (Saxenda, Victoza) | Daily (inj) | Moderate | FDA-approved for weight loss (Saxenda) | GI upset, nausea, increased heart rate | Requires daily injection |
| Dulaglutide (Trulicity) | Weekly (inj) | Low to moderate | Cardiovascular benefit, once-weekly dosing | GI upset, possible thyroid risk | Not FDA-approved for weight loss |
[P – Plan / Recommendations]
Pharmacologic Weight Management: Recommended Choice:
Monitoring and Follow-Up for Weight Loss Therapy:
Hyperlipidemia Management Suggestion:
Patient Education (Adverse Effects & Precautions):
Follow-Up Suggestion:
Final Summary:
[lab data]
2023-05-23 Anti-HBc Reactive
2023-05-23 Anti-HBc-Value 9.12 S/CO
2023-05-23 Anti-HCV Nonreactive
2023-05-23 Anti-HCV Value 0.16 S/CO
2023-05-23 HBsAg Reactive
2023-05-23 HBsAg (Value) 3336.74 S/CO
2023-05-23 Anti-HBs 0.53 mIU/mL
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
[bedside visit]
Visit Date: 2025-04-01 Visit Time: 11:15 Subject: Suspected Oxaliplatin-related Adverse Drug Reaction (ADR) and Chemotherapy-Induced Nausea and Vomiting (CINV) Management
Observation:
Assessment:
Recommendations:
[labs confirm HBV: Vemlidy maintained, medication compliance assured]
Lab results (2023-05-23) showed HBsAg and anti-HBc reactive and Vemlidy (tenofovir alafenamide) is currently in use, no medication discrepany found.
[exam finding]
[MedRec]
This is a 77-year-old male with a complex medical history, including type 2 diabetes mellitus, chronic kidney disease (CKD stage 3a), mixed hyperlipidemia, and atherosclerotic cardiovascular disease (ASCVD) post-stent ×2 (2024-12). He also has a recent diagnosis of immune thrombocytopenia (ITP) treated with Danol (danazol) and Compesolon (prednisolone), followed by a brief pulse of Medason (methylprednisolone).
He recently underwent neuroimaging revealing a chronic subdural hematoma (SDH) with mild mass effect (CT 2025-03-28), most likely secondary to severe thrombocytopenia. Blood sugar fluctuations are evident, likely aggravated by corticosteroid use. Current vital signs are stable (2025-03-31), with no signs of active bleeding, infection, or decompensation.
Problem 1. Immune Thrombocytopenia (ITP)
Problem 2. Chronic Subdural Hematoma (SDH)
Problem 3. Type 2 Diabetes Mellitus with Steroid-Induced Hyperglycemia
Problem 4. Chronic Kidney Disease (Stage 3a)
Problem 5. Atherosclerotic Cardiovascular Disease (ASCVD)
[Analysis on the appropriateness and risk-benefit considerations of antiplatelet or antithrombotic treatment]
This 77-year-old male patient has
[exam finding]
[MedRec]
[consultation]
[MultiTeam]
[radiotherapy]
[chemotherapy]
Problem 1. Metastatic Sigmoid Colon Adenocarcinoma with Disease Progression
Problem 2. Cancer-Related Pain and Symptom Management
Problem 3. Small Bowel Obstruction (SBO)
Problem 4. Myelosuppression and Prior Neutropenia
Problem 5. Nutritional and Functional Decline
[Summary]
The patient is a 50-year-old male with a history of sigmoid colon adenocarcinoma (diagnosed in 2023-05) and metastases to the liver and lungs. His clinical course has been complicated by disease progression despite multiple chemotherapy regimens, including Panitumumab + FOLFOXIRI, Avastin + FOLFOXIRI, and palliative treatments such as radiotherapy. The patient also suffers from breakthrough cancer pain, managed with a multimodal analgesic regimen, and has signed an advance directive for palliative care.
Recent data (2025-01-15) indicate the patient is receiving FOLFOXIRI with dose reductions and shows mild anemia, stable renal function, and well-compensated liver function. There are indications of cancer progression (e.g., metastases to liver and lungs). He reports psychosocial distress related to family dynamics and unresolved financial and personal concerns.
[Problems]
Problem #1: Cancer Progression (Colorectal Cancer with Metastases)
Problem #2: Cancer Pain (Breakthrough and Chronic)
Problem #3: Mild Anemia (not posted)
Problem #4: Electrolyte Imbalance (not posted)
Problem #5: Psychosocial Distress (not posted)
Problem #6: Neutropenia (resolved)
[palliative care approach for metastatic colon cancer]
The patient’s medical seeking behavior reflects a pattern of frequent visits to emergency care due to severe symptoms related to advanced sigmoid colon cancer with liver and lung metastases. The patient presents with symptoms such as abdominal pain, vomiting, breakthrough cancer pain, and infection-related concerns, often prompting visits to emergency departments.
The patient appears to seek medical attention primarily when experiencing acute or intolerable symptoms, such as severe abdominal pain (often rated as 8-10 on the VAS scale), breakthrough pain, or gastrointestinal complications (vomiting, cramping). These symptoms often align with cancer progression or complications from treatments.
In multiple instances, the patient self-reports worsening pain or new symptoms, such as fever, chills, or abdominal rigidity, indicating a tendency to seek help when experiencing significant discomfort rather than routine monitoring. Additionally, there are frequent prescriptions of pain medications (tramadol, acetaminophen, and morphine), indicating a need for continuous pain management.
The patient, a 50-year-old male with stage IV sigmoid colon cancer and metastases to the lungs and liver, has been experiencing ongoing symptoms and complications requiring frequent hospital visits for treatment and symptom management. His condition has progressed over recent months, with recurrent abdominal pain, vomiting, and severe breakthrough pain prompting multiple admissions to emergency care.
Recent Diagnoses:
Recent Imaging
Recent Treatment & Medications:
Management Plan may include:
Oral Const-K is being used for potassium supplementation, Sintrix (ceftriaxone) for suspected infection, Lactul (lactulose), Through (sennoside), and Bisadyl (bisacodyl) for constipation, and morphine and Tramacet for pain control. No medication issues have been identified.
[exam finding]
[MedRec]
2024-08-04 ~ 2024-08-25 POMR Rheumatology and Immunology Chen ZhengHong
2024-04-14 ~ 2024-04-16 POMR Gastroenterology Xiao ZongXian
2024-01-14 ~ 2024-01-22 POMR Orthopedics Zhou BoZhi
2023-12-14 ~ 2023-12-20 POMR General and Gastrointestinal Surgery Chen YanZhi
2022-05-30 ~ 2022-07-01 POMR Hemato-Oncology Xia HeXiong
2022-04-08 ~ 2022-05-05 POMR Hemato-Oncology Xia HeXiong
2022-01-06 ~ 2022-01-15 POMR Orthopedics Zhou BoZhi
2020-07-07 ~ 2020-07-19 POMR Hemato-Oncology Zhang ShouYi
This is a 45-year-old woman with a complex pain syndrome characterized by chronic lower back and extremity pain, functional limitations, and multiple comorbid neuropathies. She has a diagnosis of Complex Regional Pain Syndrome (CRPS), supported by clinical presentation, response to nerve blocks, and small fiber involvement on QST. Her pain is likely multifactorial, with contributions from:
The recent recurrent pain flare (VAS 8) and hospital readmission on 2025-03-30 align with CRPS reactivation and chronic spine pathology. The patient’s current condition is stable but vulnerable, with pain moderately controlled on ongoing nerve blocks and steroid tapering.
Problem 1. Complex Regional Pain Syndrome (CRPS)
Problem 2. Lumbosacral Degenerative Disc Disease with Radiculopathy
Problem 3. Thoracic Epidural Lesion (T5–6)
Problem 4. Small Fiber Neuropathy
Problem 5. Secondary Adrenal Insufficiency (not posted)
[lab data]
2024-10-22 HLA A-high 11:02
2024-10-22 HLA A-high 33:03
2024-10-22 HLA B-high 46:01
2024-10-22 HLA B-high 58:01
2024-10-22 HLA C-high 01:02
2024-10-22 HLA C-high 03:02
2024-10-22 HLA DQ-high 02:01
2024-10-22 HLA DQ-high 03:03
2024-10-22 HLA DR-high 03:01
2024-10-22 HLA DR-high 09:01
2024-10-04 Anti-HBc Nonreactive
2024-10-04 Anti-HBc Value 0.17 S/CO
2024-10-04 Anti-HBs 97.56 mIU/mL
2024-10-04 Anti-HCV Nonreactive
2024-10-04 Anti-HCV Value 0.09 S/CO
2024-10-04 HBsAg Nonreactive
2024-10-04 HBsAg Value 0.35 S/CO
[exam finding]
[MedRec]
[chemotherapy]
2025-03-12 - fludarabine 30mg/m2 49mg NS 500mL 30min D1-5 + cytarabine 2000mg/m2 3300mg NS 500mL 4hr D1-5 + idarubicin 8mg/m2 13mg NS 50mL 10min D1-3 (FLAG-Ida)
2025-02-10 - fludarabine 30mg/m2 49mg NS 500mL 30min D1-5 + cytarabine 2000mg/m2 3300mg NS 500mL 4hr D1-5 + idarubicin 8mg/m2 13mg NS 50mL 10min D1-3 (FLAG-Ida)
2024-12-15 - L-asparaginase 6000unit/m2 9300unit NS 500mL 2hr D1,3
2024-12-09 - L-asparaginase 6000unit/m2 9300unit NS 500mL 2hr D1,3,5 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1
2024-12-04 - daunorubicin 30mg/m2 47mg NS 100mL 30min D1-2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + cyclophosphamide 750mg/m2 1200mg NS 500mL 2hr D1
2024-11-20 - vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + L-asparaginase 6000unit/m2 9696unit NS 500mL 2hr D1,3,5
2024-11-13 - daunorubicin 50mg/m2 80mg NS 100mL 30min D1-3 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + cyclophosphamide 750mg/m2 1200mg NS 500mL 2hr D1
2024-11-08 - methotrexate 15mg IT 2min
2024-11-06 - methotrexate 15mg IT 2min
2024-10-11 - cyclophosphamide 750mg/m2 1200mg NS 500mL 2hr D1 + doxorubicin 50mg/m2 80mg NS 100mL 10min D1 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + etoposide 300mg/m2 490mg NS 25mL 3hr D1-3 + prednisolone 60mg/m2 50mg BID PO D2-5
FLAG-Ida - [Acute myeloid leukemia: Induction therapy in medically fit adults] - 2025-02-10 - https://www.uptodate.com/contents/acute-myeloid-leukemia-induction-therapy-in-medically-fit-adults
GRAALL-2003 trial - Regimens and Protocols — http://caprockhematology.com/Site/Archive_files/JCO%202009%20GRAAL%20Trial.pdf
The GRAALL-2003 study, conducted in 70 centers across France, Belgium, and Switzerland, investigated a pediatric-inspired treatment approach for adults (aged 15 to 60 years) diagnosed with Philadelphia chromosome-negative acute lymphoblastic leukemia (ALL).
The key aspects of the GRAALL-2003 protocol included:
Detailed Chemotherapy Regimen (Table 1 in the source provides a comprehensive breakdown of the GRAALL-2003 chemotherapy regimen. However, be aware that some errors in the table are corrected in an erratum at the end of the document. Here’s a summary of the key stages, incorporating the erratum’s corrections):
Problem 1. Neutropenia with Febrile Episode
Problem 2. Acute T-Cell Lymphoblastic Leukemia / Lymphoblastic Lymphoma (Refractory Disease Status)
Problem 3. Bone Marrow Suppression (Pancytopenia)
Problem 4. Hepatic Enzyme Elevation (Transaminitis)
The patient, diagnosed with acute lymphoblastic leukemia/lymphoma (ALL/LBL), has experienced significant complications including massive pleural effusion, mediastinal and neck lymphadenopathy, bone marrow involvement, and neutropenia secondary to aggressive chemotherapy. Management strategies have included multiple lines of chemotherapy (e.g., FLAG-Ida), antibiotics for neutropenic prophylaxis, and supportive care for associated symptoms like anemia and pleural effusion. While neutropenia persists as a critical concern, other parameters such as pleural effusion are under control following therapeutic interventions.
Problem 1. Neutropenia
Problem 2. Pleural Effusion
Problem 3. ALL/LBL Progression and Treatment Response
Key Findings and Insights:
Comments on Neutropenia and Thrombocytopenia:
Management Recommendations:
Clinical Improvements:
Patient Overview
Analysis of Current Regimen Alignment with GRAALL-2003 Protocol – For a 27-year-old male, a pediatric-inspired protocol, like GRAALL-2003, is appropriate as it has shown improved survival in young adults with ALL.
Patient-Specific Adjustments – The patient is 27 years old and can tolerate intensified regimens better than older adults, but certain considerations remain critical:
[FFP Not a Universal Fix for L-Asparaginase-Induced DIC]
Fresh frozen plasma (FFP) is not universally beneficial for all patients with disseminated intravascular coagulation (DIC) when receiving L-asparaginase. The use of FFP in such cases has been studied with varying outcomes:
Effectiveness and Risks: FFP is used to manage coagulation disorders induced by L-asparaginase, which can cause deficiencies in several hemostatic proteins, including fibrinogen and antithrombin III5. However, its administration carries risks such as hypervolemia and potential viral transmission5. Studies have shown that FFP does not significantly improve hemostatic parameters or prevent bleeding in some contexts, such as in critically ill neonates with DIC3.
Thrombosis Prevention: While FFP has been used to prevent thrombotic complications associated with L-asparaginase therapy, its effectiveness is debated. In adults undergoing induction therapy with L-asparaginase for acute lymphoblastic leukemia (ALL), the risk of thrombosis is high, but no clear guidelines exist on the use of FFP for thrombosis prevention2. Instead, low molecular weight heparin has been used as a prophylactic measure2.
Clinical Studies: Some studies have shown that FFP does not significantly alter coagulation parameters or improve outcomes in children receiving L-asparaginase[7][8]. For instance, a study found no beneficial effect on the hemostatic system in children receiving L-asparaginase when treated with FFP7. Another study demonstrated minimal improvement in coagulation factors after FFP administration during ALL induction therapy[8].
In conclusion, while FFP may be used in certain situations to manage coagulation disorders during L-asparaginase therapy, it is not universally effective for all patients with DIC. The decision to use FFP should be based on individual patient conditions and weighed against potential risks.
Citations: 1 https://www.semanticscholar.org/paper/e958fc7411b21acd7aaeaa0939d5a58ed1c3aaf1 2 https://www.semanticscholar.org/paper/855c9f52e9e012acf7ebe9715598f7216ed1e021 3 https://www.semanticscholar.org/paper/a7e99b199d4ede1ae884bfe53c2f336cd9248a9b 4 https://pubmed.ncbi.nlm.nih.gov/3855365/ 5 https://www.semanticscholar.org/paper/d4d1f13b6ecef34499ae64e130de9920e13386ee 6 https://www.semanticscholar.org/paper/b1109ea19930e08070234b800a5b2a3f2309452f 7 https://pubmed.ncbi.nlm.nih.gov/7524313/ [8] https://pubmed.ncbi.nlm.nih.gov/8566890/
[MedRec]
[chemotherapy]
A 49-year-old female with newly diagnosed ascending colon adenocarcinoma (cT3N1b, pT3N1b, stage III, pMMR) underwent right hemicolectomy on 2025-03-10, followed by Port-A implantation on 2025-03-26. She is now admitted for first cycle (C1) of adjuvant FOLFOX chemotherapy on 2025-03-31. Laboratory tests reveal normofunctional liver and kidneys, moderate anemia (HGB 9.0 g/dL), and marked eosinophilia (14.5%). Her chemotherapy plan follows NCCN guidelines, appropriate for stage III colon cancer.
Problem 1. Stage III Colon Adenocarcinoma (pT3N1b, pMMR)
Problem 2. Anemia
Problem 3. Eosinophilia
Problem 4. Chemotherapy Readiness and Organ Function
Problem 5. Hepatitis B Reactivation Risk
[bedside visit]
Date & Time of Visit: 2025-03-31 at 15:30
Location: 11A15
Assessment & Intervention:
During the visit, the patient was awake and alert, lying in bed with good overall spirit. A male family member or friend was also present, seated on the small bed near the window.
I asked the patient how she felt about her first cycle of chemotherapy, and whether she had been informed of the potential side effects. The patient responded that a case manager had provided a brief explanation earlier in the morning, and that she was not currently experiencing any discomfort.
I reminded her to promptly report any adverse symptoms to the healthcare team if they occur. I also informed her that after discharge, she may receive a follow-up call to inquire about her post-chemotherapy condition.
[exam finding] (not completed)
[MedRec]
2020-10-24, 2020-07-11 SOAP Obstetrics and Gynecology Hong ZhengXiu - Prescription x3 - spironolactone 25mg 1# QD 28D - Uformin (metformin 500mg) 0.5# BIDAC 28D
[surgical operation]
[radiotherapy]
[immunochemotherapy]
2025-03-24 - Phesgo (pertuzumab 600mg, trastuzumab 600mg) SC 5min
2025-02-27 - Phesgo (pertuzumab 600mg, trastuzumab 600mg) SC 5min + docetaxel 75mg/m2 148mg NS 250mL 1hr + carboplatin AUC 6 450mg NS 250mL 2hr (Herceptin + Perjecta. TCHP)
2025-02-05 - Phesgo (pertuzumab 600mg, trastuzumab 600mg) SC 5min + docetaxel 75mg/m2 146mg NS 250mL 1hr + carboplatin AUC 6 450mg NS 250mL 2hr (Herceptin + Perjecta. TCHP)
2025-01-15 - Phesgo (pertuzumab 600mg, trastuzumab 600mg) SC 5min + docetaxel 75mg/m2 146mg NS 250mL 1hr + carboplatin AUC 6 450mg NS 250mL 2hr (Herceptin + Perjecta. TCHP)
2025-12-25 - Phesgo (pertuzumab 600mg, trastuzumab 600mg) SC 5min + docetaxel 75mg/m2 146mg NS 250mL 1hr + carboplatin AUC 6 450mg NS 250mL 2hr (Herceptin + Perjecta. TCHP)
2025-12-04 - Phesgo (pertuzumab 600mg, trastuzumab 600mg) SC 5min + docetaxel 75mg/m2 146mg NS 250mL 1hr + carboplatin AUC 6 450mg NS 250mL 2hr (Herceptin + Perjecta. TCHP)
2024-11-09 - Phesgo (pertuzumab 1200mg, trastuzumab 600mg) SC 5min + docetaxel 75mg/m2 146mg NS 250mL 1hr + carboplatin AUC 6 450mg NS 250mL 2hr (Herceptin + Perjecta. TCHP, loading)
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
Patient
This 64-year-old female has two concurrent advanced malignancies:
She also has multiple chronic comorbidities: systemic lupus erythematosus (SLE), type 2 diabetes mellitus (currently with hyperglycemia), hypertension, dyslipidemia, hypothyroidism, prior myocardial ischemia, bilateral profound sensorineural hearing loss, and a right pituitary macroadenoma.
She is undergoing intensive treatment with associated risks of myelosuppression, infection, metabolic complications, and cardiovascular concerns.
Problem 1. Advanced High-grade Serous Ovarian Carcinoma (FIGO IIIA1(i))
Problem 2. Triple-negative Invasive Breast Carcinoma (ER-/PR-/HER2 equivocal, ISH-)
Problem 3. Type 2 Diabetes Mellitus with Steroid-induced Hyperglycemia
Problem 4. Cardiovascular Risk: History of Myocardial Ischemia + Ongoing Chemotherapy
Problem 5. Chronic Anemia – Likely Multifactorial (Iron Deficiency, Chronic Disease)
Problem 6. Systemic Lupus Erythematosus (SLE) – Stable
Problem 7. Hypothyroidism – Stable on Replacement
Problem 8. Bilateral Sensorineural Hearing Loss
[Findings and Recommendations]
[Dual Cancer Management: HGSOC and TNBC]
Managing a patient with two distinct primary malignancies - high-grade serous ovarian cancer (HGSOC) and triple-negative breast cancer (TNBC) - is undoubtedly complex. Concurrent or sequential treatment regimens must balance efficacy with minimizing toxicity and adverse reactions.
There is some overlap in regimens that can be used to target both high-grade serous ovarian cancer (HGSOC) and triple-negative breast cancer (TNBC).
Management Options
[exam finding]
[consultation]
This consultation is therefore requested to advise on subsequent treatment and examinations that should be arranged. - A - This 62-year-old woman has been newly diagnosed with nasopharyngeal carcinoma (NPC), confirmed by biopsy at LMD. She was admitted for cancer workup, including MRI, abdominal ultrasound, and PET/CT scan. We have been consulted regarding her case. - Please check the following: - EBV viral load - Anti-HBc - HBsAg - Anti-HCV - We will see the patient and explain the treatment plan in more detail once staging is complete. If the staging reveals T2 or higher, or if lymph node involvement is present (N-positive), please consult general surgery for port-A implantation.
[radiotherapy]
[chemotherapy]
Patient
Problem 1. Nasopharyngeal Carcinoma (Stage cT2N3M0)
Problem 2. Hematologic Suppression (Anemia, Leukopenia, Thrombocytopenia)
Problem 3. Chronic Hyponatremia and Hypokalemia
Problem 4. Nutritional and Mucosal Status (not posted)
Problem 5. Cardiopulmonary Status
[exam finding] (not completed)
[MedRec]
Patient: 51-year-old male, post-STEMI with PCI to LAD
Subjective
Objective
Assessment
Plan / Recommendation
Subjective:
The patient, a 64-year-old male, reports experiencing erectile dysfunction characterized by the ability to achieve an erection but with insufficient duration and hardness, lasting less than five minutes after penetration. He is seeking options for improvement.
He also mentioned a history of hypertension several years ago, which he believes is now resolved through consistent exercise and weight loss. He has not sought recent medical evaluation or taken any long-term medications.
During the consultation, it was revealed that his wife, who is five years younger and postmenopausal, experiences vaginal dryness and pain during intercourse. She perceives that their age makes sexual activity inappropriate, further contributing to their difficulties.
Objective:
Assessment:
Plan / Recommendation
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
2025-03-25 - pembrolizumab 200mg NS 100mL 30min + gemcitabine 1000mg/m2 1800mg NS 100mL 30min
2025-02-27 - liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr + NS 500mL 2hr + cisplatin 70mg/m2 130mg NS 500mL 2hr + KCl 10% 5mL MgSOr 10% 20mL NS 500mL 2hr
2025-01-22 - liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr + carboplatin AUC 5 700mg NS 250mL 2hr
2025-12-30 - liposome doxorubicin 30mg/m2 60mg D5W 250mL 1hr + carboplatin AUC 5 700mg NS 250mL 2hr
2024-11-08 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr + docetaxel 75mg/m2 140mg NS 250mL 6hr + carboplatin AUC 4 560mg NS 250mL 2hr
2024-10-07 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr + docetaxel 75mg/m2 140mg NS 250mL 6hr + carboplatin AUC 4 600mg NS 250mL 2hr
2024-09-09 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr
2024-08-14 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr
2024-07-22 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr
2024-07-01 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr
2024-06-11 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr
2024-05-20 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr
2024-04-29 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr
2024-04-08 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr
2024-03-18 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr
2024-02-26 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr
2024-01-31 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr
2024-01-09 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr + paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (Avastin + paclitaxel + carboplatin; Q3W)
2023-12-12 - ……………………………………. paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (……… paclitaxel + carboplatin; Q3W)
2023-11-09 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr + paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (Avastin + paclitaxel + carboplatin; Q3W)
2023-10-09 - paclitaxel 150mg/m2 270mg NS 250mL 6hr + carboplatin AUC 5 700mg NS 250mL 2hr + [docetaxel 30mg/m2 55mg + cisplatin 30mg/m2 55mg + gentamicin 40mg + NaHCO3 2800mg + NS 800mL] IP 1hr
2023-09-18 - paclitaxel 150mg/m2 270mg NS 250mL 6hr + carboplatin AUC 4 500mg NS 250mL 2hr + [docetaxel 30mg/m2 54mg + cisplatin 30mg/m2 54mg + gentamicin 40mg + NaHCO3 2800mg + NS 800mL] IP 1hr
2023-08-28 - paclitaxel 150mg/m2 270mg NS 250mL 6hr + carboplatin AUC 4 500mg NS 250mL 2hr (paclitaxel + carboplatin; Q3W)
2023-08-24 - bevacizumab 5mg/kg 600mg NS 500mL 90min (Avastin)
2023-08-07 - [liposome doxorubicin 30mg/m2 60mg D5W 250mL + carboplatin AUC 5 750mg NS 250mL] IP 90min (HIPEC)
2023-07-04 - paclitaxel 175mg/m2 300mg NS 250mL 6hr + carboplatin AUC 5 600mg NS 250mL 2hr
2023-06-12 - paclitaxel 175mg/m2 300mg NS 250mL 6hr + carboplatin AUC 5 600mg NS 250mL 2hr
2023-05-22 - paclitaxel 175mg/m2 300mg NS 250mL 6hr + carboplatin AUC 5 600mg NS 250mL 2hr
This is a 60-year-old woman with high-grade serous carcinoma of the ovary, initially diagnosed at FIGO stage IVB with widespread peritoneal and nodal metastases, and later found to have thyroid metastasis with extensive nodal involvement (Pathology 2024-12-13). She underwent neoadjuvant chemotherapy (Taxol/Carboplatin), debulking surgery with HIPEC (2023-08-07), and later a near-total thyroidectomy with radical neck dissection (2024-12-13). Disease progression was documented radiologically and clinically, with increasing CA125 (1488 on 2025-03-04), worsening anemia (Hgb 6.5–8.0 g/dL, G3, 2025-03-25), new spinal symptoms (CT 2025-03-05: L3-S1 spondylolisthesis and severe central stenosis), and persistent lymphadenopathy. She is currently receiving gemcitabine plus pembrolizumab chemotherapy (C1 on 2025-03-25) and supportive care for severe anemia, fatigue, and back pain.
Problem 1. High-grade serous ovarian carcinoma with metastases (FIGO IVB)
Problem 2. Severe anemia (G3)
Problem 3. Lumbar spondylolisthesis and spinal stenosis with cancer-related back pain
Problem 4. Metastatic thyroid involvement and neck lymphadenopathy
Problem 5. Cardiopulmonary and vascular comorbidity (HTN, prior DVT) (not posted)
[Navigating Treatment Challenges in Recurrent Ovarian Cancer]
Overview of Treatment Timeline and Disease Progression
Evidence of Disease Recurrence and Current Management
Current Chemotherapy Regimen and Consideration for Alternative Options
Recommendations for Next Steps
[sustained response to neoadjuvant and adjuvant therapy]
The patient underwent 3 cycles of paclitaxel and carboplatin neoadjuvant chemotherapy between 2023-05-22 and 2023-07-04. On 2023-08-07, she underwent surgery for ovarian cancer debulking, removal of intraabdominal malignant tumors, omentectomy, adhesiolysis, and HIPEC. Since then, she has received several cycles of paclitaxel and carboplatin adjuvant therapy. Both tumor markers, CA125 and CEA, continue to decrease, suggesting that the treatment is still effective.
2023-10-20 CA-125 (NM) 24.145 U/ml
2023-10-03 CA-125 (NM) 30.618 U/ml
2023-09-11 CA-125 (NM) 53.641 U/ml
2023-08-29 CA-125 (NM) 58.890 U/ml
2023-07-25 CA-125 (NM) 105.698 U/ml
2023-07-07 CA-125 (NM) 945.500 U/ml
2023-06-27 CA-125 (NM) 1417.280 U/ml
2023-06-06 CA-125 (NM) 1071.020 U/ml
2023-05-13 CA-125 782.100 U/mL
2023-10-20 CEA (NM) 6.433 ng/ml
2023-10-03 CEA (NM) 7.930 ng/ml
2023-09-11 CEA (NM) 9.771 ng/ml
2023-08-29 CEA (NM) 8.772 ng/ml
2023-07-25 CEA (NM) 74.188 ng/ml
2023-07-07 CEA (NM) 113.983 ng/ml
2023-06-27 CEA (NM) 95.131 ng/ml
2023-06-06 CEA (NM) 22.970 ng/ml
2023-04-22 CEA 17.240 ng/mL
Based on the PharmaCloud database, our hospital has been the exclusive healthcare provider for this patient in the past three months. Additionally, according to HIS5 records, our cardiologist issued a repeat prescription on 2023-08-18, which included Xarelto (rivaroxaban), Ulstop (famotidine), and Concor (bisoprolol). All of these medications have been added to the active medication list, and there were no issues identified during the reconciliation process.
[exam finding]
[immunochemotherapy]
Patient Evaluation
Problem 1. Metastatic Rectal Adenocarcinoma (T3N1bM1a, Stage IVA)
Problem 2. Liver Function and Transaminitis
Problem 3. Hematologic Abnormalities: Anemia
Problem 4. Electrolyte Imbalance: Hypokalemia
Problem 5. Psychiatric Support and Gastrointestinal Symptom Control
[lab data]
2025-03-18 Cyclosporine-A 101.2 ng/mL
2024-03-18 Cyclosporine-A (NM) 563.0 ng/mL
2024-03-12 Cyclosporine-A (NM) 1129.8 ng/mL
2024-03-06 Cyclosporine-A (NM) 461.0 ng/mL
2024-03-04 Cyclosporine-A (NM) >2000.0 ng/mL
2024-02-23 Cyclosporine-A (NM) >2000.0 ng/mL
2024-01-29 Cyclosporine-A 227.2 ng/mL
2024-01-25 Cyclosporine-A 88.2 ng/mL
[exam findings]
[MedRec]
[chemotherapy]
Note: Triple IST (hATG, CsA, EPAG) - Triple immunosuppressive therapy (IST) for severe AA (SAA) comprises eltrombopag (EPAG; a bone marrow stimulating agent) plus two immunosuppressive agents (horse antithymocyte globulin [hATG] and cyclosporine [CsA]). As discussed above, triple IST is generally preferred over treatment with hATG plus CsA alone (no eltrombopag). Ref: 2024-01-22 https://www.uptodate.com/contents/treatment-of-aplastic-anemia-in-adults
Problem 1. Severe Pancytopenia (Worsening)
Problem 2. Immunosuppressant Monitoring (Improved) (not posted)
Problem 3. Normofunctioning Organ Systems (Stable)
Problem 4. Type 2 Diabetes Mellitus (Discontinued Sitagliptin) (not posted)
Key Summary
Problem 1. Cyclosporine Level Fluctuations
Problem 2. Hematologic Status and Eltrombopag Initiation
[managing leukopenia and thrombocytopenia in aplastic anemia]
A 58-year-old female, newly diagnosed with aplastic anemia, began treatment with antithymocyte globulin at a dosage of 3.5mg/kg daily for five days starting on 2024-01-16. Additionally, ciclosporin at 300mg daily, divided into two doses (approximately 6mg/kg), was initiated on 2024-01-22. To manage severe leukopenia, G-CSF (filgrastim) has been administered since 2024-01-20. Due to observed thrombocytopenia episodes with platelet counts below 20K/uL, the concurrent initiation of eltrombopag with standard immunosuppressive therapy (antithymocyte globulin and cyclosporine) can also be considered.
Given the patient’s relatively young age, it might be advisable to assess eligibility and seek a match for allogeneic hematopoietic cell transplantation in advance.
[MedRec]
This is a patient with advanced gastric cancer (pT4aN1M1, signet ring cell type, HER2 3+), status post subtotal gastrectomy with B-I anastomosis and feeding jejunostomy on 2025-02-28. The patient is undergoing Trastuzumab + CapOx chemotherapy, initiated per NCCN gastric cancer guidelines for HER2-positive stage IV disease. Labs as of 2025-03-20 to 2025-03-21 reveal chronic kidney disease (eGFR 37.92 mL/min/1.73m²), mild normocytic anemia (HGB 11.3 g/dL), hypokalemia (K 3.4 mmol/L), hypoalbuminemia (albumin 3.4 g/dL), and elevated CA125 (57.2 U/mL). Vitals are stable. Serologies show past HBV infection with high anti-HBs titer.
Problem 1. Advanced Gastric Cancer (pT4aN1M1, HER2+)
Problem 2. Chronic Kidney Disease (CKD, eGFR ~38)
Problem 3. Normocytic Anemia (HGB 11.3 g/dL)
Problem 4. Electrolyte Imbalance: Hypokalemia (K 3.4 mmol/L) (not posted)
Problem 5. Nutritional Risk and Hypoalbuminemia (Albumin 3.4 g/dL) (not posted)
Problem 6. HBV Carrier Status with Immunity
[exam finding]
[MedRec]
[consultation]
[exam finding]
[MedRec]
s no fever, erythema, or wounds formation on the Lt
leg, and no dyspnea, orthopnea or legs edema. After well explain the
indication/procedure/risk to patient/family. She was admitted to our CV
ward for scheduled endovascular treatment to remove IVC filter. [surgical operation]
[chemotherapy]
The patient is a case of advanced ovarian cancer with peritoneal carcinomatosis, undergoing paclitaxel-carboplatin chemotherapy, and experiencing worsening anemia, persistent hypoalbuminemia, electrolyte imbalances, and possible disease progression (CA-125 elevation). The major concerns include severe anemia, ongoing myelosuppression, chronic malnutrition, and potential chemotherapy-associated complications.
Problem 1. Anemia
Objective (Findings & Trends)
Assessment
Recommendations
Problem 2. Hypoalbuminemia and Malnutrition
Objective (Findings & Trends)
Assessment
Recommendations
Problem 3. Electrolyte Imbalances (Hyponatremia, Hypocalcemia)
Objective (Findings & Trends)
Assessment
Recommendations
Problem 4. Possible Disease Progression (CA-125 Elevation & Persistent Ascites)
Objective (Findings & Trends)
Assessment
Recommendations
[Anemia] (since last review on 2025-01-14)
Objective (Findings and Trends)
Assessment (Analysis and Progression)
Current Status: Persistent moderate-severe anemia (HGB 7.2 g/dL, 2025-02-20), slightly improved from 6.6 g/dL (2025-01-14) but still declining compared to 8.7 g/dL (2025-01-16).
Likely Causes:
Disease Trend:
Recommendations (Next Steps)
Conclusion (not posted)
[Summary]
The patient is a 56-year-old female with a history of left ovarian clear cell carcinoma (pT2bN0M0, FIGO Stage IIB, diagnosed 2024-09-06). She has undergone debulking surgery (2024-09-06), developed complications including deep vein thrombosis (DVT) (2024-08-29) with subsequent IVC filter placement and removal (2024-09-05, 2024-10-08), and currently faces recurrent malignant ascites with evidence of metastatic peritoneal involvement. She is undergoing chemotherapy with paclitaxel and carboplatin (most recent administration 2025-01-15). The patient’s active medications address her chemotherapy regimen, anticoagulation, and symptom management.
[Problems]
Problem 1. Recurrent Malignant Ascites
Problem 2. Anemia
Problem 3. Deep Vein Thrombosis and Anticoagulation
[exam finding]
Differential Diagnosis (Descending Probability)
Additional Tests for Diagnosis
Final Thoughts
Next immediate step: Lymph node biopsy and bone marrow aspiration + flow cytometry.
[exam finding]
[exam finding]
[MedRec]
[surgical operation]
[immunochemotherapy]
2025-03-03 - Padcev (enfortumab vedotin) 60mg NS 100mL 1hr (C1D8)
2025-02-21 - Keytruda (pembrolizumab) 200mg NS 100mL 1hr + Padcev (enfortumab vedotin) 60mg NS 100mL 1hr (C1D1)
Patient: 88-year-old female
Chief Concern: Follow-up on Keytruda (pembrolizumab) + Padcev
(enfortumab vedotin) therapy, adverse reactions (skin toxicity), renal
function, and medication compliance.
[Subjective]
[Objective]
[Assessment]
[Plan / Recommendation]
Patient: 88-year-old female
Chief Concern: Follow-up on Keytruda (pembrolizumab) + Padcev
(enfortumab vedotin) initiation, adverse effects, and medication
compliance.
Subjective (S)
Objective (O)
Assessment (A)
Plan (P) - Recommendation
Patient Summary
This 88-year-old female has high-grade urothelial carcinoma (UC) of the right kidney, cT3N1M0, stage IV with renal parenchymal invasion (biopsy 2025-01-16) and suspected bladder seeding (CT 2025-01-03). Given PD-L1 negativity (CPS 0%, 2025-01-22) and CKD stage 3b, treatment options are limited.
She also has acute decompensated heart failure (LVEF 37%, pulmonary edema, NYHA IV) (CXR 2025-02-03, echo 2025-02-04), chronic kidney disease (eGFR 39.67 mL/min/1.73m², 2025-02-06), and iron deficiency anemia (Hgb 9.9 g/dL, 2025-02-06). Recent hospitalization (2025-02-02 to 2025-02-06) was due to pulmonary edema secondary to ADHF and aspiration pneumonia, which improved with diuretics (furosemide, spironolactone) and empiric antibiotics (Brosym).
Problem 1. High-Grade Urothelial Carcinoma of the Right Kidney (cT3N1M0, Stage IV)
Problem 2. Chronic Kidney Disease (CKD) Stage 3b with Progressive Renal Impairment
Problem 3. Acute Decompensated Heart Failure (ADHF) with Pulmonary Edema
Problem 4. Iron Deficiency Anemia
[exam finding]
[MedRec]
[surgical operation]
[immunochemotherapy]
[Subjective]
[Objective]
Current Medications (Requiring Skin Toxicity Consideration)
Recent Skin-Related Issues
Relevant Labs
[Assessment]
[Plan / Recommendation]
Immediate Actions
Medication Adjustments
Supportive Care
Follow-Up
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
Bedside Visit: 2025-03-19, at approximately 11:50
Patient Status:
Assessment:
Additional Notes:
[Updated Insights]
Since the last review on 2025-03-10, the patient’s condition has evolved with notable hematologic changes, chemotherapy-related complications, and ongoing management of recurrent myxoid liposarcoma.
Problem 1. Severe Chemotherapy-Induced Myelosuppression (Neutropenia, Anemia, Thrombocytopenia)
Problem 2. Chemotherapy-Associated Gastrointestinal Toxicity (Nausea, Constipation, Abdominal Distension)
Problem 3. Cardiorenal Function Monitoring Post-Chemotherapy
Problem 4. Insomnia and Psychological Well-Being
Problem 5. Monitoring for Tumor Progression and Chemotherapy Response
Conclusion
Patient Evaluation
Problem 1. Recurrent Myxoid Liposarcoma (Left Retroperitoneal)
Problem 2. Post-Chemotherapy Hematologic and Organ Function Monitoring
Problem 3. Cardiovascular Status and Chemotherapy Risk
Problem 4. Recent Infection: Pneumonia and Toxicoderma (not posted)
Conclusion
{marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma)}
[exam finding] (not completed)
[surgical operation]
[immunochemotherapy]
COPD is listed as one of the diagnoses (but not in current problem list) in this hospitalization, however no corresponding medication prescribed yet.
Some bronchodilators such as beta agonists, antimuscarinic agents, or methylxanthines might be considered later after other acute symptoms mitigated.
[exam finding]
[MedRec]
[consultation]
[immunochemotherapy]
2025-03-19 - nivolumab 240mg NS 100mL 1hr [TEMP]
2025-03-10 - ………………………… docetaxel 50mg/m2 80mg D5W 100mL 1hr + oxaliplatin 85mg/m2 140mg D5W 250mL 2hr (Y-sited Covorin) + leucovorin 200mg/m2 320mg D5W 250mL 2hr (Y-sited Oxalip) + fluorouracil 2600mg/m2 4250mg NS 500mL 24hr (infusor) (FLOT)
2025-02-20 - nivolumab 240mg NS 100mL 1hr + docetaxel 50mg/m2 80mg D5W 100mL 1hr + oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 200mg/m2 330mg D5W 250mL 2hr + fluorouracil 2600mg/m2 4250mg NS 500mL 24hr (Opdivo + FLOT)
2025-01-01 - nivolumab 240mg NS 100mL 1hr + docetaxel 50mg/m2 80mg D5W 100mL 1hr + oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 200mg/m2 330mg D5W 250mL 2hr + fluorouracil 2600mg/m2 4300mg NS 500mL 24hr (Opdivo + FLOT)
Since the last review on 2025-02-20, the patient has undergone chemotherapy (on 2025-02-20, 2025-03-10), and was admitted on 2025-03-18 for Nivolumab.
Problem 1. Adenocarcinoma of Gastric Antrum, cT3N2M0, Stage III (ECOG 1)
Problem 2. Recent Urinary Tract Infection (UTI) with Escherichia coli (this item not posted)
Problem 3. Post-Stroke Neurologic Recovery (Right Parasagittal Infarct on 2025-01-11)
Problem 4. Chronic Ischemic Heart Disease with Stable Angina
Problem 5. Type 2 Diabetes Mellitus (HbA1c 6.6 on 2025-02-03, Improved from 9.2 on 2024-12-06)
Summary of Key Actions
Since the last review on 2025-01-13, the patient has undergone significant clinical changes, including ischemic stroke, ongoing immunochemotherapy (FLOT + Nivolumab), and complications related to infections (urosepsis, vaginitis, and recurrent UTI). Problems identified are:
Additionally, the decision regarding the 2nd cycle of immunochemotherapy requires evaluation of the patient’s performance status (ECOG 1), infection control, hematologic reserves, and organ function stability.
Problem 1. Cerebrovascular Event (Acute Ischemic Stroke on 2025-01-15)
Problem 2. Hematologic and Renal Status (Anemia, Electrolyte Imbalance, Renal Function)
Problem 3. Infection Control (UTI, Vaginitis, and Sepsis)
Recommendation on 2nd Immunochemotherapy Session - Proceed with 2nd session of FLOT + Nivolumab, but with close monitoring.
[Patient Summary]
The patient, a 62-year-old female, presents with multiple complex medical issues, including:
The patient underwent neoadjuvant chemotherapy with the FLOT regimen (fluorouracil, leucovorin, oxaliplatin, and docetaxel) combined with nivolumab starting on 2025-01-01, alongside interventions to manage complications, including successful retrieval of a foreign body from the pulmonary artery (2024-12-31).
[Problem Comments]
Problem 1. Gastric Adenocarcinoma (Stage III, cT3N2M0)
Problem 2. Bloodstream Infection (Escherichia coli)
Problem 3. Anemia
Problem 4. Diabetes Mellitus
Problem 5. Cardiovascular Issues (Ischemic Heart Disease and Heart Failure)
[MedRec]
[surgical operation]
[radiotherapy]
[immunochemotherapy]
Patient Evaluation
Problem 1. Diffuse Large B-Cell Lymphoma (DLBCL), Non-GCB Subtype
Problem 2. Chemotherapy-Induced Myelosuppression (below not posted)
Problem 3. Cardiovascular Risk & LV Dysfunction
Problem 4. Thrombotic Risk
Problem 5. Splenic Involvement & Possible Autoimmune Cytopenia
Problem 6. Electrolyte & Metabolic Balance
Problem 7. Helicobacter Pylori-Associated Gastritis & Esophagitis
Conclusion
[exam finding]
[MedRec]
[immunochemotherapy]
Updated Insights on Prioritized Issues Since 2024-12-16
Problem 1. Diffuse Large B-Cell Lymphoma (DLBCL) – Treatment Response and Disease Monitoring
Problem 2. Bone Marrow Suppression – Post-Chemotherapy Cytopenias
Problem 3. Glycemic Control – Diabetes Mellitus
Problem 4. Hypertension – Blood Pressure Fluctuations
Problem 5. Thyroid Nodules – Multinodular Goiter
Summary of Prioritized Actions
[Key Summary]
The patient is an 81-year-old female with diffuse large B-cell lymphoma (non-GCB, triple expressor), Lugano stage IV, involving intra-abdominal nodes, left psoas muscle, and rectum. She also has significant comorbidities:
Currently, she is undergoing chemotherapy with polatuzumab vedotin + rituximab + cyclophosphamide + liposomal doxorubicin + prednisolone (Pola-R-CHP). Glycemic control is managed using NovoRapid (insulin aspart) and Tresiba (insulin degludec).
[Problem-Oriented Comments]
[Medication Review]
Active medication:
Summary Recommendations:
[lab data]
2025-01-09 CA-153 (NM) 40.890 U/ml
2024-10-11 CA-153 (NM) 37.080 U/ml
2024-07-16 CA-153 (NM) 36.234 U/ml
2024-04-26 CA-153 (NM) 47.504 U/ml
2024-02-02 CA-153 (NM) 48.501 U/ml
2023-10-27 CA-153 (NM) 61.014 U/ml
2023-07-28 CA-153 (NM) 198.695 U/ml
2023-05-05 CA-153 (NM) 136.84 U/ml
2023-02-02 CA-153 (NM) 69.817 U/ml
2022-09-01 CA-153 20.2 U/mL
2025-01-09 CEA (NM) 3.040 ng/ml
2025-01-08 CEA 2.99 ng/mL
2024-10-11 CEA (NM) 3.265 ng/ml
2024-08-28 CEA 2.20 ng/mL
2024-07-16 CEA (NM) 2.034 ng/ml
2024-05-06 CEA 2.07 ng/mL
2024-04-26 CEA (NM) 2.802 ng/ml
2024-02-02 CEA (NM) 3.276 ng/ml
2024-01-09 CEA 3.49 ng/mL
2023-11-10 CEA (NM) 10.493 ng/ml
2023-10-27 CEA (NM) 9.586 ng/ml
2023-09-19 CEA 5.58 ng/mL
2023-08-31 CEA 6.96 ng/mL
2023-07-28 CEA (NM) 4.836 ng/ml
2023-05-05 CEA (NM) 3.375 ng/ml
2023-02-02 CEA (NM) 2.845 ng/ml
2022-09-01 CEA 4.25 ng/mL
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[immunichemotherapy]
2025-03-12 - Avastin (bevacizumab) 500mg NS 250mL 90min
2025-01-10 - Yervoy (ipilimumab) 50mg NS 50mL 30min
2025-01-09 - Tecentriq (atezolizumab) 1200mg NS 250mL 60min
2025-01-08 - Avastin (bevacizumab) 500mg NS 250mL 90min
2024-12-05 - Yervoy (ipilimumab) 50mg NS 50mL 30min
2024-12-04 - Rybrevant (amivantamab) 350mg NS 243mL 12hr
2024-12-03 - Avastin (bevacizumab) 500mg NS 250mL 90min + Tecentriq (atezolizumab) 1200mg NS 250mL 1hr
2024-10-15 - Rybrevant (amivantamab) 350mg NS 243mL 12hr
2024-10-14 - Tecentriq (atezolizumab) 1200mg NS 250mL 1hr
2024-10-11 - Avastin (bevacizumab) 500mg NS 250mL 90min
2024-08-29 - Yervoy (ipilimumab) 50mg NS 50mL 30min
2024-08-28 - Tecentriq (atezolizumab) 1200mg NS 250mL 1hr
2024-08-27 - Avastin (bevacizumab) 500mg NS 250mL 90min
2024-07-10 - Yervoy (ipilimumab) 50mg NS 50mL 30min
2024-07-09 - Tecentriq (atezolizumab) 1200mg NS 250mL 1hr
2024-07-08 - Avastin (bevacizumab) 500mg NS 250mL 90min
2024-05-08 - Yervoy (ipilimumab) 50mg NS 50mL 30min
2024-05-07 - Tecentriq (atezolizumab) 1200mg NS 250mL 1hr
2024-05-06 - Avastin (bevacizumab) 500mg NS 250mL 90min
2024-03-06 - Yervoy (ipilimumab) 50mg NS 50mL 30min
2024-03-05 - Tecentriq (atezolizumab) 1200mg NS 250mL 1hr
2024-03-04 - Avastin (bevacizumab) 500mg NS 250mL 90min
2024-01-10 - Yervoy (ipilimumab) 50mg NS 50mL 30min
2024-01-09 - Tecentriq (atezolizumab) 1200mg NS 250mL 1hr
2024-01-08 - Avastin (bevacizumab) 500mg NS 250mL 90min
2023-12-13 - Yervoy (ipilimumab) 50mg NS 50mL 30min
2023-12-12 - Tecentriq (atezolizumab) 1200mg NS 250mL 1hr
2023-12-11 - Avastin (bevacizumab) 500mg NS 250mL 90min
2023-11-10 - Tecentriq (atezolizumab) 1200mg NS 250mL 1hr
2023-11-09 - Avastin (bevacizumab) 500mg NS 250mL 90min
2023-09-19 - Avastin (bevacizumab) 500mg NS 250mL 90min + Tecentriq (atezolizumab) 1200mg NS 250mL 1hr
2023-09-01 - Tecentriq (atezolizumab) 1200mg NS 250mL 1hr
2023-08-31 - Avastin (bevacizumab) 500mg NS 250mL 90min
2023-09-14 ~ 2024-01-29 - Tepmetko (tepotinib 225mg) 2# QDCC
2022-10-19 ~ undergoing - Femara (letrozole 2.5mg) 1# QD
[Hypokalemia (K 2.3 mmol/L on 2025-03-12)]
Objective:
Assessment:
Recommendation:
[Progressive Lower Leg Skin Lesions with Exudate] (not posted)
2025-03-17 bedside visit at around 13:30 for leg lesion. Patient resting, inquired with the primary nurse on duty. She showed the images of patient’s red lesions with exudate mainly located on the mid-calf of both legs, mostly about the size of a one to fifty TWD coin. On the left knee, there is a larger area. According to the primary nurse, the patient’s condition has been gradually worsening recently.
Objective:
Assessment:
Recommendation:
[exam finding]
2024-08-02 HBsAg Nonreactive
2024-08-02 HBsAg Value 0.42 S/CO
2024-08-02 Anti-HCV Nonreactive
2024-08-02 Anti-HCV Value 0.78 S/CO
2024-08-02 Anti-HBc Reactive
2024-08-02 Anti-HBc-Value 1.89 S/CO
2024-08-02 Anti-HBc IgM Nonreactive
2024-08-02 Anti-HBc IgM Value 0.08 S/CO
2024-08-02 Anti-HBs 18.11 mIU/mL
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
Patient Evaluation
Since the last review on 2025-02-19, the patient has received an additional cycle of FOLFOX (2025-02-18, 2025-03-14) and has undergone serial laboratory tests and imaging studies. Major trends include:
Problem #1: Chronic Kidney Disease (CKD Stage 3) – Improving
Problem #2: Progressive Anemia
Problem #3: Hypertension
Since the last review on 2025-01-15, the patient’s clinical course has demonstrated:
Problem #1: Worsening Chronic Kidney Disease (Stage III)
Problem #2: New or Progressive Pleural Effusion
Problem #3: Worsening Anemia
Problem #4: Hypertension with Wide Variability
Problem #5: Dermatological Concern - Scalp Lesion (Furuncle vs. Skin Metastasis)
[Summary]
The patient is an 81-year-old male with a complex medical history, including:
Key current issues include anemia, leukopenia, renal dysfunction, and management of malignancy. Recent imaging and lab findings reflect disease stability but ongoing treatment-related challenges.
[Problems]
Problem #1: Chronic Kidney Disease (CKD) - Stage III
Problem #2: Gastrointestinal Malignancy - Sigmoid Adenocarcinoma
Problem #3: Anemia
Problem #4: Immune Status
Problem #5: Cardiovascular Health and Atherosclerosis
Problem #6: Dermatological Concern - Furuncle with Differential Diagnosis of Skin Metastasis
[gradual FOLFOX dose increase maintains renal stability, dapagliflozin dosing guidelines for CKD patients]
FOLFOX was administered at 50% of the standard dose on 2024-08-07 and 60% on 2024-08-29. With this gradual dose increase, serum creatinine has remained around 2 mg/dL, and eGFR has stayed approximately at 30, indicating stable renal function.
Additionally, for patients with CKD and an eGFR below 25, it is recommended that Forxiga (dapagliflozin) not exceed a daily dose of 10 mg.
2024-08-29 Creatinine 1.99 mg/dL
2024-08-09 Creatinine 2.02 mg/dL
2024-08-07 Creatinine 2.27 mg/dL
2024-08-01 Creatinine 1.99 mg/dL
2024-08-29 eGFR 34.63 ml/min/1.73m^2
2024-08-09 eGFR 34.03 ml/min/1.73m^2
2024-08-07 eGFR 29.75 ml/min/1.73m^2
2024-08-01 eGFR 34.63 ml/min/1.73m^2
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
[Evaluation of Deferasirox for Iron Overload]
Indication & Justification:
Contraindications Review - Deferasirox is contraindicated in:
Recommendation:
[Patient Review]
Reevaluation of Issues Since Last Review (2025-01-22 → 2025-03-13)
Problem 1. Persistent Anemia with Thrombocytopenia
Problem 2. Renal Function Fluctuations (below not posted)
Problem 3. Persistent Inflammation / Infection Concern
Problem 4. Ongoing GI Bleeding Concern
Problem 5. Bilateral Pleural Effusions
Problem 6. Persistent Pancreatic Enzyme Elevation
Conclusion
[Candida glabrata treatment]
The urine culture sampled on 2025-01-17 revealed Candida glabrata with a colony count of 1,000 CFU/mL.
Candida glabrata treatment in adults with normal kidney function.
If fluconazole is selected, a dosage of 50 to 200 mg once daily (QD) can be considered based on the eGFR of 31.52 recorded on 2025-01-20.
[Summary]
Problem 1. Hematological Abnormalities
Problem 2. Pleural Effusion and Suspected Respiratory Compromise
Problem 3. Candida Glabrata in Urine Culture
Problem 4. Renal Function Decline
Problem 5. Poor Glycemic Control
[exam findings]
[MedRec]
[consultation]
[radiotherapy]
[immunochemotherapy]
2025-03-12 - cetuximab 500mg/m2 800mg 2hr + irinotecan 180mg/m2 150mg D5W 250mL 90min + leucovorin 400mg/m2 460mg NS 250mL 2hr + fluorouracil 2800mg/m2 3260mg NS 500mL 46hr (Erbitux + FOLFIRI. Iri 50%, FV 70%)
2025-02-20 - cetuximab 500mg/m2 800mg 2hr + irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 460mg NS 250mL 2hr + fluorouracil 2800mg/m2 3200mg NS 500mL 46hr (Erbitux + FOLFIRI 70%)
2024-12-20 - [leucovorin 20mg/m2 21mg NS 100mL 30min + fluorouracil 425mg/m2 560mg NS 100mL 10min] D1,3-6 (bolus 5-FU 70%, CCRT)
2024-12-06 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 165mg/m2 135mg D5W 250mL 1.5hr + oxaliplatin 85mg/m2 70mg D5W 250mL 2hr + leucovorin 200mg/m2 195mg D5W 250mL 2hr + fluorouracil 2400mg/m2 2370mg D5W 500mL 46hr (FOLFOXIRI + Avastin. Irino 50%, Oxalip 50%, LV 60%, 5FU 60%)
2024-11-19 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 165mg/m2 135mg D5W 250mL 1.5hr + oxaliplatin 85mg/m2 70mg D5W 250mL 2hr + leucovorin 200mg/m2 195mg D5W 250mL 2hr + fluorouracil 2400mg/m2 2360mg D5W 500mL 46hr (FOLFOXIRI + Avastin. Irino 50%, Oxalip 50%, LV 60%, 5FU 60%)
2024-10-25 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 165mg/m2 135mg D5W 250mL 1.5hr + oxaliplatin 85mg/m2 70mg D5W 250mL 2hr + leucovorin 200mg/m2 195mg D5W 250mL 2hr + fluorouracil 2400mg/m2 2350mg D5W 500mL 46hr (FOLFOXIRI + Avastin. Irino 50%, Oxalip 50%, LV 60%, 5FU 60%)
2024-09-30 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 165mg/m2 135mg D5W 250mL 1.5hr + oxaliplatin 85mg/m2 70mg D5W 250mL 2hr + leucovorin 200mg/m2 190mg D5W 250mL 2hr + fluorouracil 2400mg/m2 2350mg D5W 500mL 46hr (FOLFOXIRI + Avastin. Irino 50%, Oxalip 50%, LV 60%, 5FU 60%)
2024-09-09 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 165mg/m2 160mg D5W 250mL 1.5hr + oxaliplatin 85mg/m2 80mg D5W 250mL 2hr + leucovorin 200mg/m2 260mg D5W 250mL 2hr + fluorouracil 2400mg/m2 3100mg D5W 500mL 46hr (FOLFOXIRI + Avastin. Irino 60%, Oxalip 60%, LV 80%, 5FU 80%)
2024-08-15 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 165mg/m2 160mg D5W 250mL 1.5hr + oxaliplatin 85mg/m2 80mg D5W 250mL 2hr + leucovorin 200mg/m2 250mg D5W 250mL 2hr + fluorouracil 2400mg/m2 3090mg D5W 500mL 46hr (FOLFOXIRI + Avastin. Irino 60%, Oxalip 60%, LV 80%, 5FU 80%)
2024-07-26 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 165mg/m2 150mg D5W 250mL 1.5hr + oxaliplatin 85mg/m2 68mg D5W 250mL 2hr + leucovorin 200mg/m2 250mg D5W 250mL 2hr + fluorouracil 2400mg/m2 3075mg D5W 500mL 46hr (FOLFOXIRI + Avastin. Irino 60%, Oxalip 60%, LV 80%, 5FU 80%)
2024-07-09 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 165mg/m2 100mg D5W 250mL 1.5hr + oxaliplatin 50mg/m2 68mg D5W 250mL 2hr + leucovorin 200mg/m2 240mg D5W 250mL 2hr + fluorouracil 2400mg/m2 3000mg D5W 500mL 46hr (FOLFOXIRI + Avastin. Irino 40%, Oxalip 40%, LV 80%, 5FU 80%)
2024-06-19 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 130mg/m2 100mg D5W 250mL 1.5hr + oxaliplatin 50mg/m2 67mg D5W 250mL 2hr + leucovorin 200mg/m2 300mg D5W 250mL 2hr + fluorouracil 2400mg/m2 3800mg D5W 500mL 46hr (FOLFOXIRI + Avastin. Irino 50%, Oxalip 50%)
2024-05-31 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 180mg/m2 200mg D5W 250mL 1.5hr + leucovorin 400mg/m2 600mg D5W 250mL 2hr + fluorouracil 400mg/m2 600mg D5W 10min + fluorouracil 2400mg/m2 3800mg D5W 500mL 46hr (FOLFIRI + Avastin. Irino 60%)
2024-05-15 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 180mg/m2 170mg D5W 250mL 1.5hr + leucovorin 400mg/m2 600mg D5W 250mL 2hr + fluorouracil 400mg/m2 600mg D5W 10min + fluorouracil 2400mg/m2 3800mg D5W 500mL 46hr (FOLFIRI + Avastin. Irino 60%)
2024-04-25 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 180mg/m2 140mg D5W 250mL 1.5hr + leucovorin 400mg/m2 310mg NS 250mL 2hr + fluorouracil 400mg/m2 310mg NS 10min + fluorouracil 2400mg/m2 3800mg D5W 500mL 46hr (FOLFIRI + Avastin. Irino ?off)
2024-04-11 - bevacizumab 5mg/kg 300mg NS 100mL 1hr + irinotecan 180mg/m2 140mg D5W 250mL 1.5hr + leucovorin 400mg/m2 310mg NS 250mL 2hr + fluorouracil 400mg/m2 310mg NS 10min + fluorouracil 2400mg/m2 1900mg D5W 500mL 46hr (FOLFIRI + Avastin. Irino ?off)
Patient Evaluation
Problem 1. Metastatic Ascending Colon Adenocarcinoma (cT4aN2bM1a, Stage IVA, BRAF V600E)
Problem 2. Chronic Viral Hepatitis B
Problem 3. Lumbar Spondylosis with Severe Central Canal Stenosis
Problem 4. Ventral Hernia with Bowel Loop Herniation
Problem 5. Chemotherapy-Related Gastrointestinal and Hematologic Toxicities
Conclusion (not posted)
[exam finding]
[MedRec]
[consultation]
Post-NSTEMI, Post-PCI
[Subjective]
Chief Complaint (CC):
Current Symptoms:
Medication Adherence & Understanding:
[Objective]
Vital Signs (2025-03-12):
Physical Examination:
Laboratory Data (2025-03-07, recent reference):
Current Medications (repeat 28-day supply, as per cardiology visit 2025-03-12):
[Assessment]
Post-NSTEMI, Post-PCI with DES (2025-03-04), Now Stable
DAPT Adherence Confirmed & Reinforced
Statin Therapy is Suboptimal for Secondary Prevention
ACEI Preferred Over ARB for Post-MI Mortality Reduction
[Plan, Recommendation]
Continue DAPT (Aspirin + Ticagrelor) with Emphasis on Adherence
Statin Optimization for LDL Goal <55 mg/dL
Assess Need for Long-Term PPI Use
Follow-up & Monitoring
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
This 82-year-old male has relapsed small B-cell lymphoma with plasma cell differentiation (Stage IV), currently undergoing R-COP chemotherapy (C1 on 2025-02-14, C2 on 2025-03-10). The disease involves multiple lymph node regions and the bone marrow (PET 2025-02-14, BM biopsy 2025-01-10).
His recent clinical course has been complicated by worsening anemia (Hgb 10.5 g/dL on 2025-03-10 vs. 11.4 g/dL on 2025-02-21), persistent hypoalbuminemia (2.5 g/dL on 2025-03-10 vs. 1.8 g/dL on 2025-02-10), and hyponatremia (Na 129 mmol/L on 2025-03-10, 125 mmol/L on 2025-02-10). Hypergammaglobulinemia (IgG 9021 mg/dL on 2024-12-28) suggests an active monoclonal gammopathy, possibly Waldenström macroglobulinemia (WM) or lymphoplasmacytic lymphoma (LPL).
Other comorbidities include hypertension, diabetes mellitus with triopathy, asthma, reflux esophagitis, and benign prostatic hyperplasia.
Problem 1. Relapsed Small B-Cell Lymphoma (Stage IV)
Problem 2. Worsening Anemia
Problem 3. Persistent Hypoalbuminemia
Problem 4. Hyponatremia
Problem 5. Hyperuricemia
Problem 6. Benign Prostatic Hyperplasia (BPH)
Plan Summary
[Interpretation of Bone Marrow Biopsy Diagnosis] (not posted)
Diagnosis: Small B-cell lymphoma with plasma cell differentiation
Objective Findings
Assessment & Interpretation
Recommendation
Final Interpretation:
[Interpretation of Bone Marrow Biopsy Diagnosis] (posted)
Diagnosis: Small B-cell lymphoma with plasma cell differentiation
Objective Findings
Assessment & Interpretation
Recommendations
Final Interpretation
[exam finding]
[MedRec]
2025-03-07 ~ 2025-03-09 POMR Hemato-Oncology Xia HeXiong
2025-02-25 SOAP Hemato-Oncology Xia HeXiong
2025-02-18 SOAP Hemato-Oncology Xia HeXiong
2025-02-03 SOAP Colorectal Surgery Xiao GuangHong
2023-03-05 ~ 2023-03-10 POMR Integrative Medicine Rao LunYu
2022-11-01 ~ 2022-11-02 POMR Colorectal Surgery Xiao GuangHong
2020-07-27 ~ 2020-08-03 POMR Neurology Dai BoAn
2020-06-25 ~ 2020-06-26 POMR Urology Xu JunKai
[surgical operation]
[chemotherapy]
[exam finding] (not completed)
[MedRec] (not completed)
[immunochemotherapy]
[lab data]
2024-03-13 HBV-DNA-PCR 110000 IU/mL
2024-03-11 Anti-HBs 5.31 mIU/mL
2024-03-11 Anti-HBc Reactive
2024-03-11 Anti-HBc Value 6.06 S/CO
2024-03-11 Anti-HBe Reactive
2024-03-11 Anti-HBe Ratio 0.26 S/CO
2024-03-11 HBsAg Reactive
2024-03-11 HBsAg Value 348.93 S/CO
2024-03-11 Anti-HCV Nonreactive
2024-03-11 Anti-HCV Value 0.06 S/CO
2024-03-11 HIV Ab-EIA Nonreactive
2024-03-11 Anti-HIV Value 0.04 S/CO
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
Since the last review on 2025-02-26, the patient’s condition has shown notable changes, particularly in renal function, hematologic parameters, fluid balance, and respiratory status. The following key points summarize the latest trends:
Problem 1. Worsening Renal Function with Volume Overload
Problem 2. Persistent Infection and Pneumonia (below not posted)
Problem 3. Persistent Anemia and Thrombocytopenia
Problem 4. Electrolyte Imbalances (Na, K, Ca)
Final Plan Summary
This 85-year-old woman with recurrent diffuse large B-cell lymphoma (DLBCL), non-GCB subtype, Lugano stage IV, Ki-67 95%, IPI score 5, presents with ECOG PS 4, chronic comorbidities including hypertension, type 2 diabetes mellitus, chronic atrial fibrillation, prior left MCA infarction with right hemiparesis, and recent pneumonia over the right lung.
Key concerns from recent studies:
Problem 1. Right Lung Pneumonia
Problem 2. Recurrent Diffuse Large B-Cell Lymphoma (DLBCL) Progression
Problem 3. Cytopenia (Anemia & Thrombocytopenia)
Problem 4. Catheter-Associated Bloodstream Infection (E. coli Bacteremia, Port-A Removed 2025-02-24)
Problem 5. Rapid Weight Gain with Generalized Edema
Problem 6. Worsening Renal Function (Possible AKI)
[assessing blood counts post R-CHOP treatment]
Lab results on 2024-08-19 were generally normal. However, records indicate that neutropenia (nadir) was observed approximately two weeks after the first day of R-CHOP administration. Continued monitoring of blood cell counts is recommended to determine if G-CSF is needed.
[not meeting ANC threshold for R-CHOP]
WBC lab data:
ANC = (60.2% + 1.0%) / 100 * 2.15 x 10K/uL = 1.31 x 10K/uL
The generally accepted minimum ANC threshold for administering the R-CHOP regimen is 1,500 cells/μL. It is recommended to delay the treatment until ANC is > 1500/microL and platelet count is > 100K/uL.
[regular LVEF monitoring recommended]
This patient frequently visits the cardiology department at our hospital, with records dating back to 2017. Recent diagnoses include:
On 2024-03-18, a 2D transthoracic echocardiography estimated the LVEF at 64%. Using liposomal doxorubicin instead of conventional doxorubicin can reduce the incidence of cardiomyopathy (though not eliminate all the risk). It is recommended to regularly measure LVEF during treatment to monitor for cardiomyopathy.
[exam findings] (not completed)
[MedRec]
[consultation]
[immunochemotherapy]
[neutropenia follow-up]
Neutropenia resolved after Granocyte (lenograstim) administration for 3 consecutive days beginning on 2024-05-09.
[grade 3 neutropenia developed]
Lab results indicated an ANC of 728/uL. Caution is advised when administering a new session of R-CHOP.
Treatment should ideally be started only after the ANC has risen at least above 1000/uL.
[reconciliation]
Hypocalcemia was observed with a calcium level of 1.87 mmol/L on 2024-04-15, for which a dose of IVD Calglon (calcium gluconate) was administered, followed by a prescription for oral calcium carbonate. All other lab parameters recorded on that date were grossly within normal limits, and there were no discrepancies in medication management.
[immunochemo with graded doxorubicin addition & electrolyte management]
Liposomal doxorubicin was incorporated into the existing immunochemotherapy regimen on a gradual basis. The initial dose of 20mg was administered on 2024-01-29, followed by an escalation to 40mg on 2024-02-19.
Concomitantly, Const-K and calcium carbonate were used to manage hypokalemia (3.2mmol/L) and hypocalcemia (1.99mmol/L), respectively. No medication discrepancies were identified.
[managing low platelet counts during cancer treatment]
Since Dec 2023, this patient has exhibited persistent thrombocytopenia, well before starting the R-COP regimen on 2024-01-03. While R-COP may contribute to this condition, it should not be considered the sole cause. Thrombocytopenia could also be a manifestation of the patient’s underlying DLBCL.
Patients being treated with cytotoxic chemotherapy have a suppressed bone marrow that often cannot produce adequate platelets. It is recommended to use prophylactic platelet transfusion in these settings, assuming the patient is hospitalized, afebrile, and without active infection. A threshold platelet count of 10K/uL (transfuse for a platelet count < 10K/uL) is generally used. If fever, sepsis, or coagulopathy is present, or if the patient is not hospitalized and/or cannot be closely monitored, higher thresholds may be needed. (Ref: https://www.uptodate.com/contents/platelet-transfusion-indications-ordering-and-associated-risks)
[lab data]
2024-03-19 Anti-HBc Reactive
2024-03-19 Anti-HBc Value 7.02 S/CO
2024-03-19 Anti-HCV Nonreactive
2024-03-19 Anti-HCV Value 0.11 S/CO
2024-03-19 Anti-HBs 0.00 mIU/mL
2024-03-19 HBsAg Reactive
2024-03-19 HBsAg (Value) 3979.86 S/CO
[exam findings]
2025-02-14 CT - abdomen
2024-11-07 CT - abdomen
2024-09-17 KUB
2024-08-27 2D transthoracic echocardiography
2024-08-08 CT - abdomen
2024-07-27 ECG
2024-07-05 ECG
2024-05-22 SONO - abdomen
2024-05-21 ECG
2024-05-05 CXR erect
2024-05-05 ECG
2024-04-30 2D transthoracic echocardiography
2024-03-26 CT - abdomen
2024-03-22 2D transthoracic echocardiography
2024-01-24 T-tube cholangiography
2024-01-13 ECG
2024-01-11 CTA - chest
2024-01-08 CT - abdomen
2023-12-29 Patho - pancreas total/subtatal resection
2023-12-22 Patho - pancreas total/subtatal resection
2023-12-04 Cardiac Catheterization
2023-11-30 Myocardial perfusion SPECT with persantin
2023-11-28 2D transthoracic echocardiography
2023-11-24 Flow Volume Chart
2023-11-23 MRI - liver, spleen
2023-11-22 Patho - pancreas biopsy
2023-11-21 PTCD drainage
2023-11-20 CT - abdomen
2023-11-17 CT - abdomen
2023-11-16 SONO - abdomen
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
[Analysis of Why the Chemotherapy Regimen Changed]
The most recent chemotherapy regimen was changed on 2025-03-07 from pembrolizumab + mFOLFIRINOX (administered on 2025-02-03) to gemcitabine + nab-paclitaxel + TS-1 (tegafur/gimeracil/oteracil) + folinate.
Objective: Evidence of Treatment Failure or Disease Progression
Assessment: Rationale for Switching to Gemcitabine-Based Therapy
Recommendation: Future Considerations
[Summary]
The patient has advanced pancreatic ductal adenocarcinoma, status post Whipple operation on 2023-12-21, followed by adjuvant chemotherapy (mFOLFIRINOX started on 2024-03-18 with pembrolizumab since 2024-09-11).
Rising tumor marker CA199 (from 71.85 U/mL on 2024-09-25 to 172.71 U/mL on 2024-12-19) and imaging findings suggest possible progression of disease.
Comorbidities include type 2 diabetes mellitus with variable glycemic control, chronic kidney disease (Stage 3), and hypertension.
Lab results indicate normocytic anemia (HGB 9.7 g/dL on 2024-12-26), hypoalbuminemia (albumin 3.3 g/dL on 2024-12-26), and a history of coronary artery disease with LAD stenosis (2023-12-04 Cardiac Catheterization).
[Problems]
Tumor Progression and Chemotherapy Response
Anemia and Nutritional Deficiency
Hypertension and Coronary Artery Disease
Diabetes and Glycemic Control
[Medication Review]
Medication Appropriateness
Key Observations
[poor glycemic control: insulin initiated]
Lab results indicated poorly controlled blood sugar levels. Insulin injections have been newly initiated to address this issue.
If blood glucose levels remain above 200mg/dL for two consecutive days, increasing the insulin dosage or adding oral oral antiglycemic agents may be necessary.
[optimizing insulin dosing for high fasting glucose levels]
On 2024-05-05, a chest X-ray revealed a solitary pulmonary nodule in the RUL and ground-glass opacity in the LLL, with a CRP level of 3.9 mg/dL, suggesting an infection, currently managed with Brosym (cefoperazone, sulbactam).
The patient is on basal insulin therapy of 10 units at bedtime and bolus insulin before meals - 4 units for breakfast, 5 units for lunch, and 5 units for dinner. Despite this regimen, fasting serum glucose was recorded at 327 mg/dL on 2024-05-07 at 11:42. If such elevated levels persist, an increase in the insulin dosage should be considered.
[new-onset diabetes after pancreas surgery, potassium level for insulin user]
Approximately 16.6% of patients may develop diabetes following pancreaticoduodenectomy, with preoperative glycated hemoglobin levels above 5.4% being a predictor of new-onset diabetes. (https://doi.org/10.1016/j.jamcollsurg.2018.12.042)
The development of diabetic ketoacidosis (DKA) involves both a deficiency of insulin and an excess of glucagon, with glucagon playing a contributing but not essential role.
Insulin is a potent stimulus for hypokalaemia, sparing body potassium from urinary excretion by transporting it into cells. Given that the patient’s serum potassium was normal three days ago on 2024-03-25 and the patient is currently using insulin, it’s advisable to update the potassium level to determine the need for potassium supplementation.
[fluctuating hyperglycemia: consider increasing basal insulin]
The patient’s blood sugar levels are elevated and fluctuating, as shown by readings of 217, 181, and 361. If these high levels continue, it is recommended to increase the basal insulin dosage by 2 units.
[exam finding]
[consultation]
[radiotherapy]
[immunochemotherapy]
[note]
Atezolizumab - 2025-03-10 - https://www.uptodate.com/contents/atezolizumab-drug-information
Evaluation for the Second Administration of Tecentriq (atezolizumab)
Key Considerations for Tecentriq (atezolizumab) Administration
Tecentriq (atezolizumab) is an immune checkpoint inhibitor that can cause immune-mediated toxicities, particularly hepatotoxicity. Given the patient’s history of hepatocellular carcinoma (HCC) with portal vein thrombosis, cirrhosis, and prior liver-directed therapies (RFA, TACE, and RT), close evaluation of hepatic function, immune-related adverse events, and overall performance status is essential before proceeding with the second session.
Assessment
A. Hepatic Function
Atezolizumab requires careful consideration in patients with hepatic impairment. Liver function tests (LFTs) on 2025-03-08 reveal:
Interpretation:
Monitoring Plan:
B. Renal Function
C. Hematologic Function
D. Electrolyte Abnormalities
Monitoring Plan:
Overall Assessment and Recommendation
Recommendation:
Reassessment Timeline:
At present, Tecentriq administration is NOT recommended until further evaluation.
[exam finding]
[chemotherapy]
[exam finding]
[MedRec]
[consultation]
[immunochemotherapy]
[exam finding]
Diagnosis: 1. Ovary, right, Staging surgery— serous carcinoma, high-grade 2. Ovary, left, Staging surgery— negative for malignancy 3. Fallopian tube, right, Staging surgery— involved by serous carcinoma 4. Fallopian tube, left, Staging surgery— negative for malignancy 5. Myometrium, Staging surgery— suberosal and intramural myomas 6. Endometrium, Staging surgery— negative for malignancy 7. Cervix, Staging surgery— negative for malignancy 8. Lymph node, left iliac, dissection— metastatic carcinoma (1/6) 8. Lymph node, left obturator, dissection— negative formalignancy (0/5) 9. Lymph node, right iliac, dissection— negative formalignancy (0/11) 10. Lymph node, right obturator, dissection— negative formalignancy (0/6) 11. Lymph node, left paraaortic, dissection— metastatic carcinoma (1/3) 12. Lymph node, right paraaortic, dissection— negative formalignancy (0/3) 13. Omentum, Staging surgery— negative formalignancy 1 AJCC 8th edition pathology stage: pT2aN1a(if cM0); FIGO Stage IIIA1i
Gross description: 1. Procedure (select all that apply) Staging surgery (ATH + BSO + Bilateral pelvic and paraaortic lymph nodes dissection + infracolic omentectomy ) Note: For information about lymph node sampling, please refer to the Regional Lymph Node section.
Specimen size: Ovary, right: 10x8x5 cm Ovary, left: 2.5x2x1 cm Fallopian tube, right: 5 cm in length Fallopian tube, left: 5 cm in length Uterus: 9x6x4 cm Omentum: 43x11x1.3 cm
Specimen Integrity [NOTE: For primary ovarian tumors, if the ovary containing primary tumor is removed intact into a laparoscopy bag and ruptured in the bag by the surgeon without spillage into the peritoneal cavity (to allow for removal via laparoscopy port site or small incision), the specimen integrity should be listed as “capsule intact” with a comment explaining this in the report.]
Sections are taken and labeled as:F2024-550A1-7:right ovarina tumor, F2024-550A8:right tube, S2024-26539A1:left iliac LN, A2:left obturator LN, A3-4:right iliac LN, A5: right obturator LN, A6:left paraaortic LN, A7:right paraaortic LN, A8:cx, A9-11:corpus uteri, A12-13:left adnexae, A14:omentum
Microscopic Description: 1. Histologic Type: High-grade serous carcinoma
Histologic Grade (required for endometrioid, mucinous carcinomas, immature teratomas, and Sertoli-Leydig cell tumors) (Note: Immature teratomas can be graded using a 2-tier or 3-tier system. Endometrioid and mucinous carcinomas are graded via a 3-tier system. Clear cell carcinomas, borderline epithelial neoplasms, all other malignant sex-cord stromal and germ cell tumors are not graded.) Not applicable
Implants (required for advanced stage serous/seromucinous borderline tumors only) (Note: Serous tumor implants that were formerly classified as “invasive implants” are now classified as low-grade serous carcinoma of the peritoneum.) Not applicable
Other Tissue/ Organ Involvement: Right fallopian tube
Largest Extrapelvic Peritoneal Focus: Not applicable
Peritoneal/Ascitic Fluid: Suspicious malignancy (N2024-04776)
Regional Lymph Nodes: Left iliac– 1/6 Left obturator— 0/5 Rght iliac— 0/11 Right obturato— 0/6 Left paraaortic— 1/3 (＜ 10 mm) Right paraaortic 0/3
Additional Pathologic Findings: suberosal and intramural myomas
Comment(s): none
Immunohistochemical stains: p53:aberrant(diffuse, strong staining, ＞90%), WT-1(+), Napsin A(-), vimentin(-), CK20(-)
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
This is a 54-year-old female with high-grade serous carcinoma of the right ovary (pT2aN1a, FIGO Stage IIIA1i) s/p optimal debulking surgery (ATH + BSO + bilateral pelvic and paraaortic lymph node dissection + infracolic omentectomy on 2024-12-18), currently undergoing adjuvant chemotherapy with paclitaxel + carboplatin (latest cycle on 2025-03-06).
Her disease initially presented with abdominal fullness, pain, and massive ascites (CT 2024-12-13), with ascitic cytology suspicious for malignancy (2024-12-16, 2024-12-19). Histopathology confirmed high-grade serous carcinoma with lymph node metastasis (L iliac 1/6, L paraaortic 1/3) and peritoneal involvement (right fallopian tube, ascitic fluid positive).
Current concerns include:
Problem 1. Ovarian Cancer (High-Grade Serous Carcinoma, FIGO Stage IIIA1i, s/p Debulking Surgery)
Problem 2. Chemotherapy-Induced Hematologic Changes
Problem 3. Renal Function and Chemotherapy-Related Nephrotoxicity
Problem 4. Tumor Marker Trends and Disease Monitoring
Problem 5. ENT Concerns – Chronic Tinnitus and Eustachian Tube Dysfunction
Final Plan
[exam finding]
[MedRec]
[consultation]
[immunochemotherapy]
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
Since the last review on 2025-01-22, the patient has continued on chemotherapy with Bevacizumab (bevacizumab), Paclitaxel (paclitaxel), and Carboplatin (carboplatin) at non-regular intervals (C1 2024-10-01, C2 on 2024-11-04, C3 on 2024-11-29, C4 on 2024-12-25, C5 on 2025-01-21, C6 on 2025-03-05). The following notable updates are observed:
Problem 1. Ongoing Management of High-Grade Serous Carcinoma
Problem 2. Mild Anemia and Hematologic Recovery
Problem 3. Renal and Hepatic Function Stability
Problem 4. Persistent Microscopic Hematuria and Renal Tubular Cells in Urinalysis
Final Summary of Updates and Plan Since 2025-01-22 → 2025-03-05
| Category | Previous (2025-01-22) | Latest (2025-03-05) | Change |
|---|---|---|---|
| CA-125 (U/mL) | 6.120 (2025-01-23) | 7.900 (2025-01-09) | Stable |
| HGB (g/dL) | 11.1 (2025-01-27) | 11.5 (2025-03-04) | Slightly Improved |
| PLT (x10³/uL) | 122 (2025-01-27) | 182 (2025-03-04) | Significant Increase |
| WBC (x10³/uL) | 3.39 (2025-01-27) | 5.25 (2025-03-04) | Improved |
| Creatinine (mg/dL) | 0.44 | 0.40 | Improved |
| eGFR (mL/min/1.73m²) | 160.87 | 179.58 | Improved |
| BP (mmHg) | Normal | 160/107 (2025-03-04) | Elevated |
| Microscopic Hematuria | Absent | 3-5 RBC/HPF, RTE cells 1-5/HPF | New Finding |
Next Steps:
This patient has a history of high-grade serous carcinoma of the ovary, FIGO Stage IIA, diagnosed on 2024-08-29 (pathology report, 2024-08-29), treated with debulking surgery and subsequent cycles of Taxol (paclitaxel) + Carboplatin, with the addition of Avastin (bevacizumab) from 2024-11-04. Serial CA-125 tumor marker levels have shown improvement (477.2 U/mL on 2024-08-26 to 7.9 U/mL on 2025-01-09), suggesting treatment efficacy. Imaging studies suggest persistent omental tumor seeding (CT, 2024-12-09).
However, notable issues include:
Problem 1. Persistent Omental Lesions
Problem 2. Hematologic Trends (Anemia and Leukopenia)
Problem 3. Nutritional and Electrolyte Status (not posted)
Summary of Further Actions
Supplementary Considerations
The treatment pathway (surgery, chemotherapy, maintenance, and follow-up) adheres to NCCN recommendations for Stage IIA high-grade serous carcinoma. Genetic testing is recommended to be reviewed or considered if not performed to evaluate potential benefits from PARP inhibitors.
[role of bevacizumab and PARP inhibitors in advanced ovarian cancer care]
Pathology and Staging:
Current Treatment:
Systemic Therapy:
Maintenance Therapy Consideration:
Follow-Up and Monitoring:
Additional Recommendations:
Pathology and Staging:
Current Treatment:
Systemic Therapy:
Maintenance Therapy Consideration:
Follow-Up and Monitoring:
Recommendations for Consideration
[lab data]
2024-09-24 HBsAg Nonreactive
2024-09-24 HBsAg Value 0.33 S/CO
2024-09-24 Anti-HBc Reactive
2024-09-24 Anti-HBc Value 5.02 S/CO
2024-09-24 Anti-HCV Nonreactive
2024-09-24 Anti-HCV Value 0.19 S/CO
[exam findings]
[consultation]
[immunochemotherapy]
Patient Summary
Problem 1. Extranodal Marginal Zone Lymphoma (Left Lacrimal Gland) Under R-COP Therapy
Problem 2. Atrial Fibrillation with Valvular Disease and Pulmonary Hypertension (below not posted)
Problem 3. Persistent Mild Anemia (Likely Chemotherapy-Induced or Chronic Disease-Related)
Problem 4. History of Suspected Laryngeal Cancer (Later Found to Be Reactive Lymphoid Hyperplasia)
Conclusion
[monitoring WBC in follow-up to R-COP treatment]
Mild hypokalemia has been observed, which might be managed through potassium supplementation via tablets or diet.
Following the R-COP regimen on 2024-09-23, mild leukopenia was noted on 2024-10-04. It is recommended to continue monitoring WBC changes after the second session administered this hospitalization.
[exam findings]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
2025-03-03 - ………………………………….. irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovorin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 4500mg 500mL 46hr (FOLFIRI. hold Avastin due to colostomy has dark blood noted)
2025-01-17 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 4400mg 500mL 46hr (Avastin + FOLFIRI)
2024-12-24 - (Avastin + FOLFIRI)
2024-11-27 - (Avastin + FOLFIRI)
2024-11-08 - (Avastin + FOLFIRI)
2024-10-08 - (Avastin + FOLFIRI)
2024-09-04 - (Avastin + FOLFIRI)
2024-08-05 - (Avastin + FOLFIRI)
2024-07-15 - (Avastin + FOLFIRI)
2024-06-24 - (Avastin + FOLFIRI)
2024-06-03 - (Avastin + FOLFIRI)
2024-05-20 - (Avastin + FOLFIRI)
2024-04-19 - (Avastin + FOLFIRI)
2024-03-18 - (Avastin + FOLFIRI)
2024-02-19 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 85mg/m2 135mg D5W 250mL 2hr + leucovorin 400mg/m2 640mg NS 250mL + fluorouracil 2400mg/m2 3820mg NS 500mL 46hr (Avastin + FOLFOX)
2024-01-24 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 85mg/m2 135mg D5W 250mL 2hr + leucovorin 400mg/m2 640mg NS 250mL + fluorouracil 2400mg/m2 3840mg NS 500mL 46hr (Avastin + FOLFOX)
2024-01-02 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 85mg/m2 135mg D5W 250mL 2hr + leucovorin 400mg/m2 640mg NS 250mL + fluorouracil 2400mg/m2 3850mg NS 500mL 46hr (Avastin + FOLFOX)
2023-12-06 - (Avastin + FOLFOX)
2023-11-09 - (Avastin + FOLFOX)
2023-10-20 - (Avastin + FOLFOX)
2023-10-04 - (Avastin + FOLFOX)
2023-09-13 - (Avastin + FOLFOX)
2023-08-21 - (Avastin + FOLFOX)
2023-07-28 - (Avastin + FOLFIRI)
2023-07-12 - (Avastin + FOLFIRI)
2023-06-20 - (Avastin + FOLFIRI)
2023-05-30 - (Avastin + FOLFIRI)
2023-05-08 - (FOLFIRI)
On 2024-02-19, the patient received Avastin + FOLFOX during her current hospital stay. Lab values obtained on the same date were unremarkable except for an elevated alkaline phosphatase level at 154 U/L.
A subsequent sigmoidoscopy performed on 2024-02-20 revealed luminal narrowing up to 10cm from the anal verge. This finding suggests rectal stenosis and precluded evaluation of the primary tumor site.
No medication discrepancies were identified during the review.
[lab data]
2024-08-26 FLT3-D835 (BM) Undetectable
2024-08-23 HBsAg Nonreactive
2024-08-23 HBsAg Value 0.42 S/CO
2024-08-23 Anti-HBc Nonreactive
2024-08-23 Anti-HBc-Value 0.23 S/CO
2024-08-23 Anti-HCV Nonreactive
2024-08-23 Anti-HCV Value 0.18 S/CO
2024-08-23 HLA A-high 02:06
2024-08-23 HLA A-high 33:03
2024-08-23 HLA B-high 15:18
2024-08-23 HLA B-high 58:01
2024-08-23 HLA C-high 03:02
2024-08-23 HLA C-high 07:04
2024-08-23 HLA DQ-high 02:01
2024-08-23 HLA DQ-high 05:01
2024-08-23 HLA DR-high 03:01
2024-08-23 HLA DR-high 10:01
2024-08-22 CMV viral load assay Target Not Detected IU/mL
2024-08-22 Mycoplasma IgM Negative Index
2024-08-22 Mycoplasma IgM Value 0.2 Index
2024-08-20 Cryptococcus Ag Negative
2024-08-20 Cold hemo. <1:8
2024-08-20 BCR/abl (BM)(qual) Undetectable
2024-08-16 JAK2 (quan) 0.00 %
2024-08-16 FLT3/ITD (BM) Undetectable
2024-08-16 NPM1 (quan)(BM) Presence of mutation
2024-08-16 P.jiroveci DNA-Sp Undetectable
2024-08-15 CMV viral load assay Target Not Detected IU/mL
2024-08-15 CD2 NA
2024-08-15 CD3 2.8
2024-08-15 CD4 NA
2024-08-15 CD5 0.6
2024-08-15 CD7 0.1
2024-08-15 CD8 NA
2024-08-15 CD10 4.5
2024-08-15 CD11b 34.4
2024-08-15 CD13 96.2
2024-08-15 CD14 0.2
2024-08-15 CD15 NA
2024-08-15 CD16 0.62
2024-08-15 CD19 0.4
2024-08-15 CD19/kappa NA
2024-08-15 CD19/Lambda NA
2024-08-15 CD20 1.08
2024-08-15 CD23 NA
2024-08-15 CD25 NA
2024-08-15 CD33 99.4
2024-08-15 CD34 0.39
2024-08-15 CD38 NA
2024-08-15 CD56 0.06
2024-08-15 CD103 NA
2024-08-15 CD117 97.2
2024-08-15 CD138 NA
2024-08-15 FMC7 NA
2024-08-15 HLA-DR 56.3
2024-08-15 MPO NA
2024-08-15 TdT NA
[exam finding]
[MedRec]
[consultation]
2025-02-10 Infectious Disease
2024-12-24 Colorectal Surgery
2024-10-14 Colorectal Surgery
2024-10-09 Infectious Disease
2024-09-10 Cardiology
….-..-..
[surgical operation]
[chemotherapy]
[Step-by-Step Comprehensive Analysis and Potential Improvements for Future PBSCT Success]
What Happened?
What Could Be Improved?
What Happened?
What Could Be Improved?
What Happened?
What Could Be Improved?
What Happened?
What Could Be Improved?
What Happened?
What Could Be Improved?
Final Conclusion and Future PBSCT Considerations
If PBSCT were attempted again, earlier metabolic intervention and aggressive infectious control might have improved survival.
Since the last review on 2025-02-19 (Day -1 of allo-PBSCT), the patient’s condition has evolved significantly in the post-transplant period. The primary concerns include severe neutropenia with associated infections, worsening gastrointestinal symptoms (severe diarrhea), febrile episodes, hepatic enzyme abnormalities, and worsening anemia and thrombocytopenia.
Problem 1: Post-Allo PBSCT Severe Neutropenia & Engraftment Monitoring
Problem 2: Infection Risk & Persistent Fever
Problem 3: Severe Diarrhea & GI Mucositis
Final Summary
Next Steps:
Liver Function Adjustment Recommendations (source: UpToDate) for Schedule Conditioning Regimen (starting 2025-02-19)
[Child-Pugh Score Assessment - Class A (Score = 5)]
Child-Pugh Score Assessment - Total Child-Pugh Score: 5 points
| Parameter | Measurement | Score Criteria | Score |
|---|---|---|---|
| Total Bilirubin (mg/dL) | 0.49 | <2 mg/dL (1 point) | 1 |
| Serum Albumin (g/dL) | 4.5 | >3.5 g/dL (1 point) | 1 |
| INR | Not available (assumed stable) | <1.7 (1 point) | 1 |
| Ascites | None on exam | None (1 point) | 1 |
| Hepatic Encephalopathy | None observed | None (1 point) | 1 |
Child-Pugh Class and Interpretation
Final Classification:
Considerations:
[Patient Review]
Since the last review on 2025-02-10, the patient has undergone preparative chemotherapy for allogeneic PBSCT using Fludarabine + Busulfan (2025-02-14 to 2025-02-18), followed by Total Body Irradiation (TBI) 200cGy/2 fractions and anti-thymocyte globulin (ATG) (2025-02-18 to 2025-02-19). The patient’s ECOG performance status remains 0, with no fever, no nausea/vomiting, and stable vitals. However, the latest laboratory findings (2025-02-19) reveal significant liver enzyme elevation (ALT 1054 U/L, AST 743 U/L), mild hyponatremia (Na 134 mmol/L), and persistent anemia (Hgb 12.5 g/dL) with a declining platelet count (PLT 125 ×10³/uL from 184 ×10³/uL on 2025-02-14). Three major problems that require priority assessment:
Problem 1. Hepatic Injury (Preparative Regimen-Associated vs. SOS/VOD)
Problem 2. Hematologic Trends (Cytopenia and Myelosuppression Post-Conditioning)
Problem 3. Electrolyte Imbalance (Mild Hyponatremia and Metabolic Risks)
[Patient Evaluation Update with Lab Results (2025-02-19 12:04)]
The patient, currently undergoing haploidentical allogeneic PBSCT for AML (AMMoL, NPM1-mutated), has notable hepatic, infectious, and hematological concerns post-conditioning with Fludarabine + Busulfan + PTCy + TBI + ATG. The most recent labs (2025-02-19 12:04) reveal:
Problem 1: Severe Hepatocellular Injury (Post-Busulfan & TBI)
Problem 2: Suspected Severe Sepsis vs. Cytokine Storm
Problem 3: Post-Transplant Pancytopenia Risk (below not posted)
Summary
[Prevymis (letermovir) Administration & NHI Reimbursement Guidance]
Administration Guidelines for Nurses (according to the package insert)
Prevymis (letermovir) is used for CMV prophylaxis in CMV-seropositive allogeneic HSCT recipients (R⁺). It can be administered orally or via IV infusion. This drug is scheduled for use according to the peritransplantation regimen outlined in the Family Meeting on the afternoon of 2025-02-10.
Oral Route (Preferred)
IV Infusion (If Oral Intake is Not Feasible)
Tube Feeding Considerations
Duration of Use
Important Considerations & Precautions
NHI Reimbursement Guidance for Physicians
To ensure reimbursement, prior approval from the NHI is required.
Eligible Patients:
Usage Restriction:
Action Required:
Summary
Problem 1. Persistent Acute Myelomonocytic Leukemia (AMMoL)
Problem 2. Pre-Transplant Infection Risk
Problem 3. Atrial Fibrillation & Cardiac Considerations
Problem 4. Nutritional and Gastrointestinal Concerns (below not posted)
Problem 5. Hematologic & Electrolyte Stability
[prognostication and risk stratification in this patient with acute myelomonocytic leukemia (AMMoL)]
Prognostic Implications
Final Prognostic Interpretation
Recommendation for Next Steps
Conclusion
[Filgrastim Use in Breastfeeding Mothers]
To Nurse Practitioner Ni YiJia,
The patient’s daughter is currently breastfeeding and plans to use Filgrastim (G-CSF) to mobilize peripheral blood stem cells for her father’s transplant.
UpToDate states that endogenous G-CSF can be detected in breast milk, and concentrations increase for at least three days post-administration. While recombinant G-CSF is not absorbed orally in infants and adverse effects in breastfeeding infants are rare, some manufacturers advise against breastfeeding during therapy and for two weeks after.
The package insert recommends weighing the benefits of treatment and breastfeeding before making a decision. Pharmacokinetics:
[MedRec]
[mediction]
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
[S – Subjective]
Chief Complaint:
Patient Narrative:
[O – Objective]
Active Medications:
Recent Medication Change:
Recent Blood Glucose Readings:
Chemotherapy Education & Side Effects:
[A – Assessment]
Diarrhea – Improving
Chemotherapy Side Effects – Monitoring Required
Pancreatic Exocrine Insufficiency – Protase Not on Active List
Blood Glucose Management – Hypoglycemia Risk
[P – Plan]
Medication Adjustments:
Patient Education & Counseling:
Dietary & Glucose Management:
Follow-Up & Coordination:
Next Steps:
[Patient Evaluation]
The patient has pancreatic ductal adenocarcinoma (PDAC), Stage IV (peritoneal carcinomatosis confirmed via biopsy on 2024-12-24). Molecular profiling (NGS 2025-01-24) revealed KRAS G12V mutation, which currently lacks FDA-approved targeted therapies but may be sensitive to experimental pan-KRAS inhibitors or MEK inhibitors in clinical trials.
The patient is undergoing systemic intravenous (IV) chemotherapy with nab-paclitaxel (Abraxane) and intraperitoneal (IP) gemcitabine, an approach aimed at improving local control of peritoneal metastases. Tumor marker trends show CA19-9 decreasing (from 582.05 U/mL on 2025-01-14 to 415.33 U/mL on 2025-02-06), suggesting partial response.
Key clinical considerations:
Problem 1. Pancreatic Cancer with Peritoneal Seeding (Stage IV, KRAS G12V Mutation)
Problem 2. Systemic Effects of Chemotherapy & Cancer (Hematologic, Renal, Nutritional Status) (below not posted)
Problem 3. Pleural Effusion / Disease Progression Monitoring
Final Staging Confirmation
[Assessment of ACTOnco+ Gene Test Results]
The ACTOnco+ test for this patient identified the KRAS G12V mutation with an allele frequency of 4.8%, but no significant copy number variations, gene fusions, or microsatellite instability (MSI) could be determined due to low tumor purity (<30%). Additionally, tumor mutational burden (TMB) could not be assessed.
Summary & Recommendations
Next Steps:
[Recommendation to add Protase (pancrelipase) to active medication list]
Dear Dr./Nurse Practitioner,
I am writing to recommend the addition of Protase (pancrelipase) 280mg, 1 tablet TID to the patient’s active medication list once the diarrhea symptoms have improved.
Rationale for Recommendation:
Proposed Plan:
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
Summary
Problem 1: Neuroendocrine Carcinoma – Systemic Treatment Response
Problem 2: Renal Function Decline
Problem 3: Metabolic Changes – Low Uric Acid and LDH (below not posted)
Conclusion:
[Patient Summary]
This is a 63-year-old male with a complex medical history, primarily notable for pancreatic neuroendocrine tumor (PNET) with liver metastases, recurrent metastatic disease, and secondary primary lung adenocarcinoma. He has undergone extensive surgical interventions, radiofrequency ablation (RFA), and systemic chemotherapy over the years. Disease progression includes liver metastases, mediastinal lymph node involvement, and systemic complications like hoarseness due to vocal cord paralysis. He has a history of chronic hepatitis B and hypertension, and his treatments have included targeted therapies (e.g., sunitinib) and systemic chemotherapy. Current ongoing treatment involves etoposide-carboplatin for metastatic neuroendocrine tumor.
Key areas of concern include the ongoing metastatic burden in the liver and lymph nodes, hoarseness (2024-10-30 thyroplasty), and maintaining the balance between disease control and side effect management.
[Problem Comments]
Problem 1. Metastatic Neuroendocrine Tumor (Liver and Lymph Nodes)
Problem 2. Secondary Primary Lung Adenocarcinoma
Problem 3. Hepatitis B, Liver and Kidney Funtion
[exam finding]
[MedRec]
[radiotherapy]
[chemotherapy]
2025-02-04 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
2025-01-08 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-12-17 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-11-26 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-11-05 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-10-15 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-09-24 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-08-27 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-08-06 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-07-16 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-06-25 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-06-04 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-05-07 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-04-16 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-04-02 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 2000mg NS 500mL 24hr (Avastin + FOLFIRI)
2024-03-19 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-03-05 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-02-20 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-01-30 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-01-16 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (Avastin + FOLFIRI)
2023-09-13 - irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 250mL 46hr (FOLFIRI)
2023-08-23 - irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 250mL 46hr (FOLFIRI)
2023-08-02 - irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 250mL 46hr (FOLFIRI)
2023-07-12 - irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 4600mg NS 250mL 46hr (FOLFIRI)
2023-06-28 - irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 4600mg NS 250mL 46hr (FOLFIRI)
2023-06-14 - irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 4600mg NS 250mL 46hr (FOLFIRI)
2023-05-19 - irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 4600mg NS 250mL 46hr (FOLFIRI)
2023-05-04 - irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg NS 250mL 46hr (FOLFIRI)
2023-04-07 (FOLFIRI)
2023-03-22 (FOLFIRI)
2023-03-08 (FOLFIRI)
2023-02-22 (FOLFIRI)
2022-02-23 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (FOLFOX)
2022-02-09 (FOLFOX)
2022-01-26 (FOLFOX)
2022-01-12 (FOLFOX)
2021-12-29 (FOLFOX)
2021-12-15 (FOLFOX)
2021-12-01 (FOLFOX)
2021-11-17 (FOLFOX)
2021-11-03 (FOLFOX)
2021-10-20 (FOLFOX)
2021-10-01 (FOLFOX)
2021-09-09 (FOLFOX)
This is an 83-year-old male with a history of sigmoid colon adenocarcinoma (pT3N1bM0, stage IIIB), multiple lung and liver metastases, chronic viral hepatitis B with delta-agent, hypertensive heart disease, type 2 diabetes mellitus, and benign prostatic hyperplasia. He was admitted on 2025-02-25 due to generalized weakness, malaise, acute back pain, and confusion, leading to an ED visit where hypotension and tachycardia were noted. Given sepsis with lactic acidosis, acute kidney injury (AKI), worsening anemia, and thrombocytopenia, a DNR order was placed, and the patient is under comfort care. Key findings and concerns:
Problem 1. Sepsis with Multiorgan Dysfunction
Problem 2. Acute Kidney Injury and Electrolyte Imbalance
Problem 3. Hematologic Abnormalities (Anemia and Thrombocytopenia)
Problem 4. Cardiac Dysfunction (Atrial Fibrillation with RVR, Myocardial Strain)
No medication reconciliation issues have been identified for this patient.
The patient appears to be tolerating the current regimen well, and his labs are mostly within normal ranges, with the exception of slightly elevated liver function tests and BUN.
[exam finding]
2025-02-25 ECG
2025-02-24 CT - abdomen
2025-02-10 PTCD (percutaneous transhepatic cholangial drainage) revision
2025-02-03 ECG
2025-02-03 CXR
2025-01-24 Percutaneous gall bladder drainage, PTGBD
2025-01-24 SONO - abdomen
2025-01-23 SONO - abdomen
2025-01-22 Sono- and fluoro-guide drainage of ascites
2025-01-21 Esophagogastroduodenoscopy, EGD
2025-01-20 MR cholangiography, MRCP
2025-01-16 SONO - abdomen
2025-01-13 CT - abdomen
2025-01-13 CXR
2024-10-18 CT - chest
2024-10-11 MRI - brain
2024-09-23 Tc-99m MDP bone scan with SPECT
2024-05-28 Tc-99m MDP bone scan with SPECT
2024-05-25 MRI - brain
2024-05-09 CT - chest
2024-02-16 Tc-99m MDP bone scan with SPECT
2024-02-15 MRI - brain
2024-02-07 CT - chest
2023-09-05 MRI - brain
2023-08-23 CT - chest
2023-08-22 Tc-99m MDP bone scan
2023-05-26 MRI - brain
2023-05-04 Tc-99m MDP whole body bone scan
2023-05-03 CT - chest
2023-02-02 Tc-99m MDP whole body bone scan
2023-02-01 CT - chest
2023-01-30 MRI - brain
2022-11-17 Tc-99m MDP whole body bone scan
2022-11-01 CT - chest
2022-09-30 Patho - brain/meninges (tumor)
2022-09-28 MRA - brain
2022-09-28 CT - brain
2022-08-05 Tc-99m MDP whole body bone scan
2022-08-04 CT - chest
2022-05-10 CT - chest
2022-05-06 Tc-99m MDP whole body bone scan
2022-02-10 CT - chest
2022-02-07 Tc-99m MDP whole body bone scan
2021-11-11 Tc-99m MDP whole body bone scan
2021-11-10 CT - chest
2021-08-11 Tc-99m MDP whole body bone scan
2021-08-10 CT, lung/mediastinum/pleura:
2021-08-10 SONO, breast:
2021-08-10 Doppler color flow mapping, 2D transthoracic echocardiography
2021-07 right breast palpable mass with oozing and purulent discharge were noted.
[MedRec]
[counsultation]
[immunochemotherapy]
The patient is a 54-year-old female with HER2-positive metastatic breast cancer (cT4bN1M1, Stage IV), with known metastases to lungs, liver, bones, and brain. She has a history of palliative chemotherapy and targeted therapy, including trastuzumab emtansine (Kadcyla) and trastuzumab deruxtecan (Enhertu). Disease progression has been evident, with worsening hepatic metastases, new-onset obstructive jaundice, and complications including electrolyte imbalances (hypokalemia, hypocalcemia, hypomagnesemia), anemia, and acute kidney injury (AKI). She has undergone percutaneous gallbladder drainage (PTGBD) and percutaneous transhepatic cholangial drainage (PTCD) revisions to manage biliary obstruction. Palliative care involvement was discussed, and DNR preference was documented but lacked family signatures earlier.
Recent imaging reveals progressive liver, lung, and bone metastases, splenomegaly with portal vein encasement, and new ECG findings of sinus tachycardia with old anterolateral/inferior infarcts. Given her hepatic dysfunction, biliary drainage, and ongoing palliative care discussions, careful monitoring and symptom-directed management are essential.
Problem 1. Hepatic Dysfunction with Obstructive Jaundice
Problem 2. Electrolyte Imbalances (Hypokalemia, Hypocalcemia, Hypomagnesemia)
Problem 3. Anemia
Problem 4. Acute Kidney Injury (AKI)
Problem 5. Cardiac Concerns (ECG Abnormalities) - Objective - 2025-02-26 ECG: Sinus tachycardia, old inferior/anterior infarcts. - Prior ECG (2025-02-03): T-wave abnormality, possible anterior ischemia. - Mildly elevated BP and tachycardia seen in recent vitals (2025-02-26).
Problem 6. Palliative Care and Goals of Care Discussion
[reconciliation]
[patient education]
[exam finding]
[surgical operation]
[radiotherapy]
[chemotherapy]
[medication]
[Ref]
Systemic therapy regimens for metastatic pancreatic cancer: FOLFIRINOX - 2025-02-25 - https://www.uptodate.com/contents/image?imageKey=ONC%2F79571
Systemic therapy regimens for pancreatic cancer: Modified FOLFIRINOX - 2025-02-25 - https://www.uptodate.com/contents/image?imageKey=ONC%2F109546
[ChatGPT 4o] (not posted)
Based on my review of the NCCN guidelines for breast cancer (2024-10-15) and pancreatic adenocarcinoma (2024-08-02), the following insights are relevant to the patient’s case:
[Patient]
This 58-year-old female with a history of ductal carcinoma in situ (DCIS) of the left breast (2018, s/p BCT+SLND, CR) and recently diagnosed pancreatic head adenocarcinoma (pT2N2, stage III, 2025-01-03, s/p Whipple operation) is now undergoing adjuvant FOLFIRINOX (2025-02-25) per NCCN guidelines (2024-08-02, pancreatic cancer).
She initially presented with epigastric fullness (2024-10), progressive jaundice (2025-01), weight loss (6kg in one month), and abnormal liver function tests. Workup confirmed a pancreatic head tumor (2.7 cm, MRCP 2024-11-29) with lymphovascular invasion and N2 lymph node metastases (12/24 positive, Whipple pathology 2025-01-06).
She is currently on FOLFIRINOX (2025-02-25) with supportive care, including GASMIN (dimethylpolysiloxane), Protase (pancrelipase), and Through (sennoside) for GI support.
[Problems]
Problem 1. Pancreatic Adenocarcinoma (pT2N2, Stage III, s/p Whipple, Adjuvant FOLFIRINOX)
Problem 2. Post-Whipple Nutritional and Digestive Issues
Problem 3. Hematological and Inflammatory Markers
Problem 4: Electrolyte Imbalance (Hypokalemia, Hypocalcemia)
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
2025-01-21 - oxaliplatin 50mg/m2 65mg D5W 250mL 2hr (Y-sited Covorin) + leucovorin 300mg/m2 400mg NS 250mL 2hr (Y-sited Oxalip) + fluorouracil 300mg/m2 400mg NS 250mL 10min + fluorouracil 2200mg/m2 2700mg NS 500mL 46hr (FOLFOX)
2024-11-26 - oxaliplatin 50mg/m2 70mg D5W 250mL 2hr (Y-sited Covorin) + leucovorin 300mg/m2 430mg NS 250mL 2hr (Y-sited Oxalip) + fluorouracil 300mg/m2 430mg NS 250mL 10min + fluorouracil 2200mg/m2 3000mg NS 500mL 46hr (FOLFOX)
2024-10-08 ~ undergoing - Xeloda (capecitabine 500mg) 1# TID
2024-09-25 ~ 2024-10-02 - Xeloda (capecitabine 500mg) 2# BID
2024-09-09 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 250mL 10min + fluorouracil 2200mg/m2 3300mg NS 500mL 46hr (FOLFOX)
2024-08-23 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 250mL 10min + fluorouracil 2200mg/m2 3300mg NS 500mL 46hr (FOLFOX)
2024-08-06 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 250mL 10min + fluorouracil 2200mg/m2 3300mg NS 500mL 46hr (FOLFOX)
2024-07-17 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 480mg NS 250mL 2hr + fluorouracil 300mg/m2 480mg NS 250mL 10min + fluorouracil 2200mg/m2 3500mg NS 500mL 46hr (FOLFOX)
2024-06-26 - oxaliplatin 50mg/m2 75mg D5W 250mL 2hr + leucovorin 300mg/m2 480mg NS 250mL 2hr + fluorouracil 300mg/m2 480mg NS 250mL 10min + fluorouracil 2200mg/m2 3500mg NS 500mL 46hr (FOLFOX)
2024-06-03 - ………………………………….. leucovorin 300mg/m2 480mg NS 250mL 2hr + fluorouracil 300mg/m2 480mg NS 250mL 10min + fluorouracil 2200mg/m2 3500mg NS 500mL 46hr (FOLFOX without Oxa)
This 83-year-old female has gastric adenocarcinoma (pT3N3b, cM0, Stage IIIC) post-total gastrectomy (2024-04-17) with D2 lymph node dissection, followed by concurrent chemoradiotherapy (FOLFOX-based chemotherapy and radiotherapy 45 Gy/25 fx completed 2024-11-04). She has multiple comorbidities, including type 2 diabetes mellitus (DM), hypertension (HTN), chronic hepatitis B (anti-HBc reactive), and a history of sepsis.
Her recent clinical course is complicated by pneumonia (Klebsiella pneumoniae, sputum culture 2025-02-01), sepsis (Coagulase-negative Staphylococcus, blood culture 2025-01-30), progressive anemia, severe thrombocytopenia, and electrolyte imbalances (hyponatremia, hyperkalemia, hypocalcemia).
Key recent findings: - Multifocal pneumonia (CXR 2025-02-23) with persistent bilateral lung opacities and consolidations. - Progressive anemia (Hgb 9.9 g/dL, 2025-02-24) and thrombocytopenia (PLT 69 x10³/uL, 2025-02-24). - Severe hyponatremia (Na 122 mmol/L, 2025-02-24). - Metabolic acidosis (HCO3 12.1 mmol/L, BE -10.7 mmol/L, 2025-02-23) and hyperkalemia (K 5.9 mmol/L, 2025-02-23). - Elevated inflammatory markers (CRP 23.8 mg/dL, 2025-02-23; NT-proBNP 9756.9 pg/mL, 2025-02-23). - Underlying chronic liver parenchymal disease (Abdominal SONO 2025-02-05). - History of anterior infarct (ECG 2025-02-03) and frequent premature ventricular complexes (PVCs) (ECG 2024-04-18).
Current treatment: - Active chemotherapy with Xeloda (capecitabine) 500 mg TID (since 2024-10-08) - Antibiotics: Sintrix (ceftriaxone) IV for pneumonia - Supportive care: Baraclude (entecavir), Megest (megestrol), Wecoli (bethanechol), Avelox (moxifloxacin), Rivotril (clonazepam), etc.
The key concerns are ongoing infection, electrolyte disturbances, anemia/thrombocytopenia, and overall disease progression.
Problem 1. Multifocal Pneumonia
Problem 2. Severe Hyponatremia
Problem 3. Progressive Anemia and Thrombocytopenia
Problem 4. Metabolic Acidosis and Hyperkalemia
Final Remarks
[Gastric Adenocarcinoma (pT3N3b, cM0, Stage IIIC) Post-Gastrectomy and Chemoradiotherapy] (not posted)
The primary focus now is assessing for recurrence, optimizing chemotherapy, and improving supportive care to maintain functional status.
[monitoring renal function in FOLFOX treatment]
The patient’s renal function is showing a declining trend. Despite the dose reduction of oxaliplatin in the FOLFOX regimen, if the renal function continues to deteriorate, it may be necessary to reassess the treatment regimen.
2024-07-17 Creatinine 1.30 mg/dL
2024-07-09 Creatinine 0.96 mg/dL
2024-06-26 Creatinine 0.74 mg/dL
2024-07-17 eGFR 41.58 ml/min/1.73m^2
2024-07-09 eGFR 58.99 ml/min/1.73m^2
2024-06-26 eGFR 79.66 ml/min/1.73m^2
[evaluation of iron and vit B12 status following total gastrectomy]
Lab data:
The above lab results suggested that the patient has adequate vitamin B12 and iron levels, which is particularly important following total gastrectomy due to the risk of deficiencies associated with reduced absorption capacities. The elevated vitamin B12 may be due to supplementation, and while not typically harmful, should be monitored to ensure dosages are appropriate. Regular follow-up is crucial to monitor these levels, adjust supplementation as necessary, and check for any signs of micronutrient deficiencies that might not yet be apparent.
[exam findings]
[immunochemotherapy]
[exam finding]
2025-02-23 CXR
2025-02-05 Neck soft tissue
2025-02-05 Nasopharyngoscopy
2025-01-24 SONO - Thyroid
2025-01-19 KUB
2025-01-19 CXR
2024-12-17 CXR
2024-12-13 CT - chest
2024-12-04 Endoscopic Retrograde Cholangiopancreatography, ERCP
2024-12-04 2D transthoracic echocardiography
2024-12-03 T-tube cholangiography
2024-12-02 CXR
2024-11-12 T-tube cholangiography
2024-11-11 ECG
2024-10-29 PET
2024-10-09 SONO - abdomen
2024-10-06 Percutaneous Gall Bladder Drainage, PTGBD
2024-10-05 CT - abdomen
2024-10-05 KUB
2024-10-05 CXR
2024-09-23 CXR
2024-09-10 CT - chest
2024-06-26 2D transthoracic echocardiography
2024-06-14 PET
2024-06-03 Patho - lymphnode biopsy
2024-05-27 Nasopharyngoscopy
2024-05-25 CXR
2024-05-17 Patho - colon biopsy
2024-05-17 Pathology Level IV
2024-05-17 EGD
2024-05-06 Endoscopic Retrograde Cholangiopancreatography, ERCP
2024-04-30 SONO - abdomen
2024-04-28 KUB
2024-04-15 CT - abdomen
2024-04-12 Colonoscopy
2024-04-08 Patho - stomach biopsy
2024-04-06 EGD
2024-04-02 CT - neck
2024-01-29 PET
2024-01-10 Patho - lymphnode biopsy
2023-12-30 CT - chest
2023-11-08, -11-07 Bladder Sonography
2023-11-07 24hr Holter ECG
2023-11-07 2D transthoracic echocardiography
2023-11-06 MRA - brain
2023-11-06 Neurosonography
2023-11-04 ECG
2023-11-04 CT - brain
2023-09-20 Neurosonography
2023-09-20 Brainstem auditory evoked potential, BAEP
2023-09-13 MRI - larynx
2023-09-13 Sound Field Audiometry
2023-08-30 ENT Hearing Test
2023-06-15 Nasopharyngoscopy
2023-06-05 Nasopharyngoscopy
2023-03-31 CXR
2023-03-30 KUB
2023-03-29 CXR
2023-03-29 PET
2023-03-28 Patho - bone marrow biopsy
2023-03-28 2D transthoracic echocardiography
2023-03-17 Patho - thyroid total/lobe
2023-03-17 Frozen Section - thyroid
2023-03-16 CXR
2023-03-09 CT - chest
2023-02-20 Patho - lymphnode biopsy
2023-02-07 CT - neck
2023-02-01 Nasopharyngoscopy
2022-11-02 Flow Volume Loop
2022-09-23 Hearing Test
2022-08-26 Hearing Test
2022-07-29 Hearing Test
2022-07-05 2D transthoracic echocardiography
2022-07-07 Neurosonology
2022-07-01 ENT Hearing Test
2022-06-21 MRA - brain
2022-06-20 CXR
2022-06-14 CTA - chest
[MedRec]
[consultation] (not completed)
2025-02-05 Ear Nose Throat
2024-12-03 Gastroenterolgy
2024-12-02 Diagnostic Radiology
2024-10-08 Infectious Disease
….-..-..
2023-03-28 General and Digestive Surgery
[surgical operation]
[immunochemotherapy]
Revised Edition of Hematologic Oncology Chemotherapy Drug Prescription (in hospital regimen collection, version 2022-07-04)
Rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP21) for non-Hodgkin lymphoma 2023-06-06 https://www.uptodate.com/contents/image?imageKey=ONC%2F63586&topicKey=HEME%2F4729
Cycle length: 21 days.
Regimen
Pretreatment considerations:
Monitoring parameters:
Suggested dose modifications for toxicity:
Older patients with DLBCL generally have a worse prognosis compared to younger patients due, in part, to more comorbid conditions and lower treatment tolerance. 2023-06-06 https://www.uptodate.com/contents/initial-treatment-of-advanced-stage-diffuse-large-b-cell-lymphoma
Since the last review on 2025-01-20, the patient has undergone significant developments, including recurrent infection, persistent anemia, lymphoma progression, and initiation of R-GemOx chemotherapy. The three most pressing concerns are:
Problem #1: Residual Infection/Inflammation
Problem #2: Hematologic Status (Anemia and Chemotherapy Risks)
Problem #3: Lymphoma Progression and Treatment Feasibility
Final Considerations
This patient was not suitable for immediate chemotherapy following admission due to clinical signs suggesting a potential infection, which requires stabilization and resolution prior to starting or resuming chemotherapy.
Infection Signs
If Infection is Ruled Out or Recovered - If the suspected infection is treated or deemed non-significant, chemotherapy may proceed. However, certain contraindications or precautions should be addressed:
[Deliberation for Chemotherapy Conduction] (not posted)
Problem #1: Potential Infection
Problem #2: Hematologic Abnormalities
Problem #3: Organ Function and Comorbidities
Problem #4: Lymphoma Progression and Chemotherapy
[Patient Summary]
The patient, an 89-year-old woman, has a complex medical history, including diffuse large B-cell lymphoma (DLBCL), relapsed after treatment with R-miniCHOP, type 2 diabetes mellitus, hypertension, dyslipidemia, chronic viral hepatitis B, and multiple other comorbidities.
She is currently undergoing chemotherapy with R-GemOx as of 2025-01-06. Recent clinical findings indicate progressive interstitial lung disease (ILD) and continued challenges with lymphoma management. Additionally, complications such as gallstones, biliary tract issues, and nutritional challenges are notable.
Key issues revolve around lymphoma progression, treatment complications, and comorbidity management.
[Problem Comments]
Problem #1: Relapsed Diffuse Large B-Cell Lymphoma (DLBCL)
Problem #2: Interstitial Lung Disease (ILD)
Problem #3: Biliary Tract and Gallbladder Issues
Problem #4: Type 2 Diabetes Mellitus
Problem #5: Nutritional and Overall Functional Status
Our endocrinologist wrote a repeat prescription for Zulitor (pitavastatin), Trajenta (linagliptin 5mg) and Dibose (acarbose 100mg) on 2023-08-02 and the drugs are included in the formulary with no reconciliation issue identified.
On 2023-06-08, our neurologist issued a refillable prescription for Plavix (clopidogrel) and diphenidol, and on 2023-06-23, our otolaryngologist prescribed Strocain (oxethazaine polymigel), Acetal (acetaminophen), and cephalexin. Apart from diphenidol, which is no longer necessary due to the resolution of vertigo, all other validly prescribed drugs mentioned have been incorporated into the active medication list without any reconciliation issues.
This patient visited local medical doctor on 2023-05-26, 2023-05-28, 2023-05-29, 2023-05-30, 2023-06-01, 2023-06-04 for her myositis, functional dyspepsia, acute upper respiratory infection, and prescribed acetaminophen, diazepam, loratadine and opium derivatives. for each a short 3-day valid prescription. These symptoms are generally covered in current medical problem list and managed with corresponding same or similar therapeutic class medications. No medication reconciliation issues identified.
Given that this patient has been diagnosed with myositis and dyspepsia that have persisted for months according to the PharmaCloud database, it’s plausible that these could be indicative of statin-induced muscle side effects. Clinical experience suggests that a change in dosing frequency, such as alternate day dosing, may improve statin tolerability in patients experiencing adverse effects such as myalgia. This strategy is particularly beneficial for patients who cannot tolerate daily statin therapy. In addition, alternate-day statin therapy is also considered a cost-effective method to improve drug utilization (Ref: Efficacy and Safety of Alternate-Day Versus Daily Dosing of Statins: a Systematic Review and Meta-Analysis. Cardiovasc Drugs Ther. 2017;31(4):419-431). Considering the information from these studies and the fact that the laboratory data indicate an improvement in the patient’s hyperlipidemia, it is recommended that the administration of Zulitor be changed from 0.5# QD to 0.5# QOD.
Due to the patient’s advanced age, R-miniCHOP (a dose-reduced version of R-CHOP with reduced amounts of cyclophosphamide and vincristine) was selected as treatment starting on 2023-03-31. One episode of leukopenia was observed (1.56K/uL on 2023-04-12) and was alleviated with two consecutive days of Granocyte (lenograstim) administration. Please monitor for recurrence of leukopenia after this 2nd dose of R-miniCHOP.
Beta-2 microglobulin (b2M) is a major histocompatibility complex (MHC) class I molecule found on the surface of nearly all nucleated cells in the body. Cells with a high turnover rate, such as immune cells and cancer cells, tend to produce and express higher levels of b2M on their surface. In non-Hodgkin’s lymphoma, cancer cells may also have elevated levels of b2M. The elevated levels of b2M observed around the trough of leukopenia may indicate the destruction of cancerous B cells.
Lab data showed that levels above the ULN are associated with type 2 diabetes and hyperlipidemia. Dibose (acarbose), Trajenta (linagliptin) and Zulitor (pitavastatin) are currently appropriately prescribed.
The patient’s cerebral atherosclerosis is treated with Plavix (clopidogrel) and her hepatitis B is treated with Baraclude (entecavir) without an issue.
Hypothyroidism is listed as a diagnosis for the patient, but there is no corresponding medication prescribed currently. The serum free T4 level on 2023-03-17 was 0.57 ng/dL, which is slightly below the normal range. It is recommended to reevaluate the patient’s condition and consider prescribing appropriate medication, such as levothyroxine, if necessary to manage her hypothyroidism.
[drug identification]
The three requested drugs have been identified as follows:
An in-hospital porter will be sent to deliver these medications to the patient’s ward.
[lab data]
2024-04-25 HBsAg Nonreactive
2024-04-25 HBsAg Value 0.49 S/CO
2024-04-25 Anti-HBc Reactive
2024-04-25 Anti-HBc Value 5.73 S/CO
2024-04-25 Anti-HBs 2.11 mIU/mL
2024-04-25 Anti-HCV Nonreactive
2024-04-25 Anti-HCV Value 0.13 S/CO
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
[Thrombocytopenia]
Objective
Assessment
Recommendation
Patient Summary
Problem 1. Hyperbilirubinemia and Liver Dysfunction
Problem 2. Thrombocytopenia and Leukopenia (Bone Marrow Suppression)
Problem 3. Hypertension (Suboptimally Controlled)
Problem 4. Hypomagnesemia
[Thrombocytopenia: Trend and Recent Observations]
The patient exhibits a clear and sustained trend of thrombocytopenia (platelet count <150 × 10³/μL), with a recent drop to 46 × 10³/μL on 2024-12-04, reflecting moderate to severe thrombocytopenia.
Platelet Trend Analysis:
| Date | Platelet Count (×10³/μL) | Comments |
|---|---|---|
| 2024-12-04 | 46 | Current; worsening trend. Moderate to severe thrombocytopenia. |
| 2024-11-11 | 50 | Persistent thrombocytopenia; stable but low. |
| 2024-10-14 | 68 | Mild improvement noted but still below normal. |
| 2024-08-29 | 77 | Slightly higher but still thrombocytopenic. |
| 2024-06-25 | 64 | Persistent thrombocytopenia; evidence of fluctuation. |
| 2024-05-31 | 61 | Continuation of low platelet counts. |
| 2024-05-28 | 30 | Severe thrombocytopenia during hospitalization. |
| 2024-05-25 | 45 | Further decline during acute illness. |
| 2024-04-25 | 72 | Baseline thrombocytopenia; evidence of early issues before treatment. |
Causes of Thrombocytopenia in this Patient:
Key Observations in Recent Labs:
Management Recommendations:
[Findings and Management]
Key Findings:
Clinical Concerns
Recommendations
[recommended voriconazole TDM for impaired liver function]
No CRE or VRE culture positives were found, but Aspergillus antigen was confirmed.
For invasive Aspergillosis, voriconazole is usually recommended at a dosage of 6 mg/kg IV/PO Q12H on day 1, followed by 4 mg/kg IV/PO Q12H. However, according to the package insert, in patients with mild to moderate liver impairment (Child-Pugh Class A and B), the standard loading dose should be used, but the maintenance dose should be halved. There are no recommendations for patients with severe liver impairment (Child-Pugh Class C) (Ref: Sanford Guide).
This patient weighs 73 kg. According to the Sanford Guide, the dosing should be 438 mg Q12H on day 1 and then 292 mg Q12H from day 2. Given the patient’s poor liver function, voriconazole therapeutic drug monitoring (TDM) is highly recommended to adjust the maintenance dose.
To order a voriconazole trough level test:
[hyperammonemia management and lactulose dose consideration]
Lactul (lactulose) has effectively controlled the hyperammonemia. If serum ammonia levels remain within the normal range for these days, a reduction in the lactulose dosage or even discontinuation may be considered.
[liver cirrhosis Child-Pugh B classified & Medication Review]
The patient’s discharge diagnoses on 2024-05-17 included cirrhosis of the liver, classified as Child-Pugh Class A.
However, recent lab results indicate a revised classification to Child-Pugh Class B. This is based on updated values: Alb 2.9 g/dL (2 points), PT 13.7 seconds (3 points), and BilT 2.15 mg/dL (3 points). Even encephalopathy and ascites were not counted, these scores total at least 8 points, should be classfied as Class B.
The currently used medications have been reviewed for this Child-Pugh Class B patient, no other medications except Tramacet should be dose adjusted. Use of Tramacet is not recommended as acetaminophen and tramadol undergo extensive hepatic metabolism.
[exam finding]
[MedRec]
[consultation]
2024-12-26 Ear Nose Throat
2024-12-26 Neurology
2024-09-02 Gastroenterolgoy
Sigmoidoscopy for tissue biopsy and stent insertion was indicated if the patient and family could take the risk (organ perforation, etc.)
Explain to the family the indications, procedure, possible complications, stent placement, and related out-of-pocket expenses for a sigmoidoscopy.
If anesthesia is required, please send for anesthesia evaluation.
Colon prepare with EVAC must be done before procedure
Avoid anticoagulants/antiplatelets use if no contraindication
Correct thrombocytopenia and coagulopathy
If the patient and the family all understand the Sigmoidoscopy intervention, would take the risk, and sign the permit for Sigmoidoscopy, the sigmoidoscopy will be arranged on 2024/09/02 afternoon.
2024-08-31 Colorectal Surgery
[immunochemotherapy]
[exam finding]
[consultation]
[MedRec]
[chemotherapy]
This is an 82-year-old female with pancreatic head ductal adenocarcinoma (T4N2M1, stage IV) with liver metastasis, lymph node invasion, duodenal obstruction, and suspected peritoneal carcinomatosis. She has undergone multiple FOLFIRINOX chemotherapy cycles (starting 2024-10-01) and AXIOS LAMS gastrojejunostomy (2025-01-14) for duodenal obstruction. Complicating her condition are:
Problem 1. Pancreatic Head Adenocarcinoma (T4N2M1, Stage IV) with Liver Metastases and Duodenal Obstruction
Problem 2. Progressive Anemia and Hypoalbuminemia (Nutritional Decline and Chronic Inflammation)
Problem 3. Suspected Bone Metastases vs. Benign Compression Fracture
Problem 4. Electrolyte Imbalance (Hyponatremia, Hypocalcemia) (not posted)
[lab data]
2024-11-07 HBV-DNA-PCR Target Not Detected IU/mL
2024-09-13 HBsAg Nonreactive
2024-09-13 HBsAg Value 0.37 S/CO
2024-09-13 Anti-HBc Reactive
2024-09-13 Anti-HBc-Value 5.52 S/CO
2024-09-13 Anti-HCV Nonreactive
2024-09-13 Anti-HCV Value 0.26 S/CO
[exam finding]
[MedRec]
[consultation]
[radiotherapy]
[immunochemotheerapy]
The patient is a 59-year-old male with gastric adenocarcinoma (cT3N3bM1, Stage IV, HER2-negative, CPS: 10%) with metastases to the lungs, liver, regional and distant lymph nodes, bones, and adrenal glands. He has been undergoing palliative immunochemotherapy (Nivolumab + FOLFOX) and supportive care with Xgeva (denosumab) for bone metastases since 2024-11-06. His recent condition (2025-02-17) includes:
Given the above, the disease is progressing despite partial responses in some areas (CT 2025-01-08, compared with previous scans). The key concerns include hematologic deterioration, tumor progression, obstructive uropathy, and treatment tolerance.
Problem 1. Progressive Hematologic Deterioration (Anemia & Thrombocytopenia)
Problem 2. Tumor Progression (Increasing CA199 & Bone Metastases)
Problem 3. Obstructive Uropathy of Left Kidney
Problem 4. Nasal Bleeding and Epistaxis
[exam finding]
[MedRec]
[surgical operation]
[chemotherapy]
The patient, a 49-year-old male, has advanced squamous cell carcinoma of the ventral tongue, floor of the mouth, and lower lip with bilateral lymph node involvement (cT4aN2cM0, stage IVA), undergoing induction chemotherapy with the TPF regimen (Docetaxel + Cisplatin + Fluorouracil). He has multiple comorbidities, including secondary hypertension, diabetes mellitus with neuropathy, hyperlipidemia, and a history of coronary artery disease (CAD). His hospital course has been complicated by methicillin-resistant Staphylococcus aureus (MRSA) pneumonia, a urinary tract infection (UTI) due to Staphylococcus lugdunensis, and drug-induced aplastic anemia.
Problem 1. Acute Pulmonary Symptoms: Cough, Dyspnea, and Lung Infiltration
Problem 2. Chemotherapy-Related Toxicity (Myelosuppression and Gastrointestinal Symptoms)
Problem 3. Cardiovascular Risk and Hypertension
[exam finding]
[MedRec]
[surgical operation]
[Summary]
The patient, a 63-year-old male, has stage IVB non-small cell lung cancer (NSCLC) (cT4N3M1c) with multiple brain metastases, adrenal metastases, and bone metastases. The primary tumor is located in the left lower lung lobe (LLL) with significant systemic involvement. The patient has undergone right frontal craniotomy (2025-01-13) for metastatic brain tumors, palliative whole brain radiotherapy (WBRT) (since 2025-02-06, 17.5 Gy/7 fractions as of 2025-02-14, planned 30 Gy/12 fractions), and palliative radiation therapy for T3 spinal metastases (planned 30 Gy/10 fractions starting 2025-02-17).
Recent imaging (PET 2025-01-17, CT 2025-01-07) confirms progression of intracranial and systemic metastases. The PD-L1 expression is high (TPS 100%, PD-L1 22C3, 28.8, SP142 positive), supporting immunotherapy consideration. EGFR mutation testing is negative (2025-01-17), ruling out targeted therapy for EGFR-driven NSCLC.
The patient exhibits leukocytosis with neutrophilia (WBC 37.13 x10³/uL, neutrophils 98.1% on 2025-02-17), suggesting an active inflammatory/infectious process. Mild normocytic anemia (Hgb 10.3 g/dL, HCT 33.0% on 2025-02-17) and hypoalbuminemia (2.8 g/dL on 2025-02-17) indicate chronic illness-related malnutrition. Electrolyte abnormalities, including hypernatremia (149 mmol/L on 2025-02-17), hypokalemia (3.6 mmol/L on 2025-02-17), and mild hypocalcemia (2.14 mmol/L on 2025-02-17), require correction.
Cardiac evaluation shows cardiomegaly (CXR 2025-02-17) and impaired left ventricular relaxation (Echo 2025-01-09). The enlarged prostate with LUTS, bilateral renal stones, and adrenal metastases (CT 2025-01-09) require urological monitoring.
[Problems]
Problem 1. Stage IVB NSCLC with Multiple Metastases (Brain, Bone, Adrenal)
Problem 2. Severe Leukocytosis with Neutrophilia (Possible Infection vs. Paraneoplastic)
Problem 3. Anemia and Hypoalbuminemia (Malnutrition, Cancer Cachexia)
Problem 4. Electrolyte Imbalances (Hypernatremia, Hypokalemia, Hypocalcemia)
[exam finding]
[MedRec]
[consultation]
[medication]
This is an 88-year-old female with a history of right lower lobe lung adenocarcinoma (cT4N0M1a, stage IVA) (CT 2023-01-17, Pathology 2023-02-03) with EGFR exon 21 (L858R) mutation on Iressa (gefitinib) since 2023-04-14. She also has end-stage renal disease (ESRD) (eGFR 7.62 mL/min/1.73m², Labs 2025-02-16) secondary to chronic kidney disease (CKD) stage 5, type 2 diabetes mellitus (DM), and hypertension, complicated by anemia (Hgb 7.6 g/dL, Labs 2025-02-16) and volume overload with suspected pulmonary edema. She was admitted on 2025-02-16 due to progressive dyspnea over 3 days, leg edema for 1 month, and bilateral lower limb pain for 2 weeks. Key Clinical Issues:
Problem 1. Pulmonary Edema & Pleural Effusions
Problem 2. ESRD & Worsening Azotemia
Problem 3. Severe Anemia
Problem 4. Hypertension & Cardiac Dysfunction
Problem 5. Musculoskeletal Concerns
[exam finding]
[MedRec]
A 91-year-old male with multiple comorbidities, including non-insulin-dependent diabetes mellitus (NIDDM), coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), and senile dementia, was admitted on 2025-02-15 due to persistent fever for seven days despite antibiotic treatment in Kaohsiung. He has ECOG 4, indicating a poor functional status and dependency on full assistance. Key findings include:
Problem 1. Persistent Fever and Suspected Infection
Problem 2. Glycemic Variability and NIDDM
Problem 3. Liver Dysfunction (Elevated ALT, AST, Hypoalbuminemia)
Problem 4. Electrolyte Imbalance (Hypocalcemia)
[exam finding]
2025-02-11 Bronchodilator Test, BDT
2025-02-07 ECG
2024-12-27 Pathology - prancreas total/subtotal resection
2024-12-20 Body fluid cytology - bile duct brushing
2024-12-20 Endoscopic Ultrasonography, EUS
2024-12-19 Pathology - distal CBD
2024-12-18 Endoscopic Retrograde Cholangiopancreatography, ERCP
2024-12-17 T-tube cholangiography
2024-12-16 Endoscopic Ultrasonography, EUS
2024-12-13 Magnetic Resonance CholangioPancreatography, MRCP
2024-12-10 Percutaneous Gall Bladder Drainage, PTGBD
2024-12-09 ECG
2024-12-03 CT - abdomen
2024-12-03 SONO - abdomen
2023-11-03 2D transthoracic echocardiography
[MedRec]
2025-02-11 SOAP Hemato-Oncology Xia HeXiong
2024-12-10 ~ 2025-01-16 POMR General and Gastroenterological Surgery Wu ChaoQun
2024-11-22 SOAP Cardiology Liu ZhiRen
2024-08-30 SOAP Cardiology Liu ZhiRen
2024-06-07 SOAP Cardiology Liu ZhiRen
2024-03-08 SOAP Cardiology Liu ZhiRen
2024-01-12 SOAP Cardiology Liu ZhiRen
2018-04-23 SOAP Cardiology Liu ZhiRen
2018-02-26 SOAP Cardiology Liu ZhiRen
2017-01-05 SOAP Orthopedics Zeng XiaoZu
[consultation]
[surgical operation]
The patient is a 62-year-old woman with tubular adenocarcinoma of the ampulla of Vater (pT3bN1, Stage IIIA) post-Whipple procedure (2024-12-26). She experienced postoperative complications, including bile leakage and intra-abdominal infection (VRE and Candida). Currently, she is planned receiving adjuvant chemotherapy with FOLFIRINOX (this hospitalization). Multiple organ systems require close monitoring, especially considering her past medical history (hypertension, type 2 diabetes mellitus, hyperlipidemia) and ongoing complications (small airway disease and dizziness).
Problem 1. Postoperative Pancreatic Cancer Management and Adjuvant Therapy
Problem 2. Risk of Hepatitis B Virus (HBV) Reactivation
Problem 3. Electrolyte Imbalance (Hypokalemia)
Problem 4. Pulmonary Function – Small Airway Disease and Dizziness
Problem 5. Cardiovascular Risk (Hypertension and Hyperlipidemia)
[exam finding]
[MedRec]
This patient presents with suspected right lung cancer with ipsilateral pleural and lung metastases and right iliac bone metastasis, accompanied by significant respiratory, cardiovascular, metabolic, and musculoskeletal complications. Key findings include:
Problem 1. Suspected Right Lung Cancer with Metastases
Problem 2. Pleural Effusion and Respiratory Insufficiency
Problem 3. Cardiovascular Risks (Atrial Fibrillation, Hypertension, NT-proBNP Elevation)
Problem 4. Bone Metastases & Osteoporotic Fractures
[lab data]
2025-02-10 HLA A-high 11:01
2025-02-10 HLA A-high 33:03
2025-02-10 HLA B-high 40:01
2025-02-10 HLA B-high 58:01
2025-02-10 HLA C-high 03:02
2025-02-10 HLA C-high 07:02
2025-02-10 HLA DQ-high 03:01
2025-02-10 HLA DQ-high 03:02
2025-02-10 HLA DR-high 04:03
2025-02-10 HLA DR-high 11:01
2025-01-08 CMV viral load assay Target Not Detected IU/mL
2025-01-02 CMV IgM Reactive
2025-01-02 CMV IgM Value 2.16 Index
2024-12-31 BM Chromosome Analysis
2024-12-25 FLT3-D835 (BM) Undetectable
2024-12-25 NPM1 (qual)(BM) Presence of mutation
2024-12-23 FLT3/ITD (BM) Presence of mutation
2024-12-23 JAK2 (quan) 0.00 %
2024-12-20 HbA1c 8.5 %
2024-12-18 HBV-DNA-PCR Target Not Detected IU/mL
2024-12-16 Bone marrow cell morphology assessment with differential
cell count 2024-12-16 Age/Sex 73/M
2024-12-16 Clinical information acute leukemia
2024-12-16 Cellularity Hyper.
2024-12-16 M/E ratio 97/3
2024-12-16 Myelo.Blast 76.0 %
2024-12-16 Myelo.Pro. 0 %
2024-12-16 Myelo.Myelo. 5.0 %
2024-12-16 Myelo.Meta. 1.3 %
2024-12-16 Myelo.Band. 7.0 %
2024-12-16 Myelo.Seg. 0.7 %
2024-12-16 Lymphoid series 6.7 %
2024-12-16 Monocyte 0 %
2024-12-16 Plasma cell 1.0
2024-12-16 Megakaryocyte - LPF
2024-12-16 Ery.Pronormo. 0 %
2024-12-16 Ery.Nor.Basophilic 0 %
2024-12-16 Ery.Nor.Poly. 2.3 %
2024-12-16 Ery.Nor.Ortho. 0 %
2024-12-16 MPO negative
2024-12-16 CAE pending
2024-12-16 ANAE pending
2024-12-16 HBsAg Nonreactive
2024-12-16 HBsAg Value 0.44 S/CO
2024-12-16 Anti-HCV Nonreactive
2024-12-16 Anti-HCV Value 0.11 S/CO
2024-12-16 Anti-HBc Reactive
2024-12-16 Anti-HBc Value 5.28 S/CO
[exam finding]
[MedRec]
[chemotherapy]
2025-02-11 - cytarabine 20mg/m2 37mg BID SC 2min D1-7 (venetoclax + low dose cytarabine)
2024-12-24 - daunorubicin 45mg/m2 85mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 192mg 24hr D1-7
Venetoclax - 2025-02-12 - https://www.uptodate.com/contents/venetoclax-drug-information
Treatment Optimization for AML
Current Dose: 100 mg QDCC (started on 2025-02-11).
Recommended NCCN/Uptodate Dosage:
Action Plan:
Risk Consideration:
Current Dose: 20 mg/m² SC BID (started 2025-02-11).
Plan:
Supportive Care Suggestions
Medication Review
[Prognostic and Treatment Implications of Key Genetic and Laboratory Findings]
[Key Summary]
[Problem-Oriented Comments]
Objective:
Assessment:
Recommendations:
[Active Medication Review]
Drug-Drug Interaction:
[Treatment Recommendations for AML]
Given this patient’s age (73 years), comorbidities (CAD, CKD stage III, and DM), and clinical presentation of hyperleukocytosis (WBC = 66.36 x10³/uL, blasts = 22%), an individualized approach is preferred.
Bone marrow biopsy with cytogenetics and molecular testing (e.g., FLT3, IDH1/IDH2 mutations) to guide therapy.
Assess eligibility for targeted therapy if actionable mutations are detected:
Summary
[exam finding]
[MedRec]
[consultation]
[immunochemotherapy]
The 92-year-old male patient has diffuse large B-cell lymphoma (DLBCL, Stage IV, IPI:3) with bilateral pleural effusion, chronic kidney disease (CKD) stage 3a, type 2 diabetes mellitus, and hypertensive heart disease. He is undergoing R-COP chemotherapy (rituximab, cyclophosphamide, vincristine, prednisolone) every three weeks, with C4 administered on 2025-02-11. Recent findings include:
Problem #1: Diffuse Large B-cell Lymphoma (DLBCL, Stage IV, IPI:3)
Problem #2: Bilateral Pleural Effusion and Suspected Pneumonia
Problem #3: Chronic Kidney Disease (CKD) Stage 3a
Problem #4: Hypokalemia
Problem #5: Herpes Simplex (Resolved)
Suggested Plan
Primary Diagnosis: Diffuse Large B-cell Lymphoma (DLBCL)
Bilateral Pleural Effusion
Chronic Kidney Disease (CKD) Stage 3
Type 2 Diabetes Mellitus (T2DM)
Hypokalemia
Chronic Obstructive Pulmonary Disease (COPD)
Herpes Simplex Infection
Cardiac Considerations
Nutritional Deficiency
This is a 91-year-old male with diffuse large B-cell lymphoma (DLBCL) undergoing his second cycle of R-mini COP chemotherapy. His clinical course is complicated by chronic kidney disease (stage 3a), type 2 diabetes mellitus, atherosclerotic heart disease, chronic obstructive pulmonary disease (COPD) with acute exacerbation, electrolyte imbalance, and bilateral pleural effusions requiring recurrent interventions. He presents for chemotherapy with additional findings of dyspnea, hypocalcemia, hypoalbuminemia, and signs of malnutrition.
[lab data]
2025-02-11 AFP 80.2 ng/mL
2024-08-26 AFP 11.1 ng/mL
2024-05-20 AFP (NM) 10.166 ng/ml
2024-02-23 AFP (NM) 5.445 ng/ml
2023-12-21 AFP (NM) 3.987 ng/ml
2023-11-24 AFP (NM) 3.797 ng/ml
2023-09-04 AFP (NM) 3.347 ng/ml
2023-03-16 AFP (NM) 3.428 ng/ml
2022-12-08 AFP (NM) 3.545 ng/ml
2022-08-19 AFP (NM) 2.289 ng/ml
2022-06-14 AFP 5.3 ng/mL
2022-05-03 AFP 18.6 ng/mL
2022-05-06 PIVKA-II 377.37 mAU/mL
2022-05-04 ICG (Indocyanine green) 5.5 %
2022-05-04 HBV DNA-PCR (quan) 94.4 IU/mL
2022-05-04 HBeAg Nonreactive
2022-05-04 HBeAg (Value) 0.365 S/CO
2022-05-03 HBsAg Reactive
2022-05-03 HBsAg (Value) 815.43 S/CO
2022-05-03 Anti-HCV Nonreactive
2022-05-03 Anti-HCV Value 0.05 S/CO
[exam finding]
[MedRec]
[consultation]
2025-02-11 Dermatology
2024-11-15 Hemato-Oncology
2024-11-15 Radiation Oncology
2022-05-31 Chest Medicine
2022-05-03 Cardilogy
[surgical operation]
[radiotherapy]
[immunochemotherapy]
This is a 69-year-old man with hepatocellular carcinoma (HCC) with duodenal invasion and bleeding (pT3N0M0, Stage IIIA), previously treated with left hepatic lobectomy (2022-05-12), transarterial chemoembolization (TACE, 4 cycles: 2024-06-03, 2024-07-18, 2024-09-03, 2024-11-08), immunotherapy with atezolizumab (Tecentriq) + bevacizumab (Avastin) (2024-07-18 to 2024-11-07), and radiotherapy (2024-11-25 to 2024-12-25: 4140 cGy/23 fractions to the viable liver tumor and duodenal area for bleeding control).
Despite these interventions, he developed progressive disease with increased AFP (from 11.1 ng/mL on 2024-08-26 to 80.2 ng/mL on 2025-02-11), recurrent gastrointestinal (GI) bleeding, and a large duodenal tumor (EGD 2024-11-14). He was admitted on 2025-02-11 for first-line chemotherapy with FOLFOX. However, FOLFOX is not listed as an NCCN guideline (2025-01-10 version 4.2024) recommended regimen for HCC.
The key issues include:
Problem 1. Progressive Hepatocellular Carcinoma (HCC) with Duodenal Invasion and Bleeding
Problem 2. Hematologic Concerns (Anemia & Thrombocytopenia)
Problem 3. Chronic Hepatitis B with Potential Hepatic Decompensation Risk
Recommendations
[exam finding]
[MedRec]
[radiotherapy]
[chemotherapy]
2025-02-10 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 2800mg/m2 4400mg NS 500Ml 46hr (Avastin + FOLFIRI 10% off)
2025-01-06 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 2800mg/m2 4400mg NS 500Ml 46hr (Avastin + FOLFIRI 10% off)
2024-12-13 - (Avastin + FOLFIRI 10% off)
2024-11-29 - (Avastin + FOLFIRI 10% off)
2024-11-11 - (Avastin + FOLFIRI 10% off)
2024-10-14 - (Avastin + FOLFIRI 10% off)
2024-09-18 - (Avastin + FOLFIRI 10% off)
2024-08-31 - (Avastin + FOLFIRI 10% off)
2024-08-16 - (FOLFIRI)
2023-04-26 - (FOLFOX)
2023-04-03 - (FOLFOX)
2023-03-20 - (FOLFOX)
2023-03-02 - (FOLFOX)
2023-02-17 - (FOLFOX)
2023-02-01 - (FOLFOX)
2023-01-06 - (FOLFOX)
2022-12-23 - (FOLFOX)
2022-12-09 - (FOLFOX)
2022-11-25 - (FOLFOX)
2022-11-11 - (FOLFOX)
2022-10-27 - (FOLFOX)
2022-07-18 - (5FU CCRT)
2022-07-11 - (5FU CCRT)
2022-07-04 - (5FU CCRT)
2022-06-27 - (5FU CCRT)
2022-06-20 - (5FU CCRT)
2022-06-15 - (5FU CCRT)
This 65-year-old male with a history of rectal adenocarcinoma (cT3N1M0, initially stage IIIa) post Da Vinci low anterior resection (2022-09-23) and FOLFOX chemotherapy x12 cycles, has lung metastases (cT3N1M1, stage IV) confirmed via biopsy (2024-07-22, VATS wedge resection of right lung lesions). He is currently receiving FOLFIRI + Avastin (bevacizumab) Q2W, with C5D1 administered on 2025-02-10.
Key developments since last review on 2025-01-06:
Tumor Marker Trends:
Chemotherapy Response & Adjustments:
Imaging Follow-Up (CT 2024-12-16):
Hematologic & Biochemical Trends (2025-02-10 vs. 2025-01-14):
No HBV Reactivation (on Baraclude (entecavir), ALT stable).
No Severe Toxicities Observed:
Problem 1. Metastatic Rectal Adenocarcinoma – Lung Metastases
Problem 2. Chemotherapy-Related Toxicities
Problem 3. Liver & Renal Function – Chemotherapy Monitoring
Problem 4. Overall Clinical Status & ECOG Performance
Summary of Recommendations
Overall, the patient is clinically stable, responding well to chemotherapy, and tolerating treatment without major complications. Further monitoring is required to ensure disease control and manage chemotherapy-related side effects effectively.
[Patient Summary]
This patient is a 65-year-old male with a history of rectal adenocarcinoma, initially staged as cT3N1M0 (2022-05-17 colonoscopy and pathology) and ypStage IIA post low anterior resection (LAR) on 2022-09-23 (2022-09-26 pathology). After completing chemoradiotherapy (CCRT) with 5-FU and 12 cycles of FOLFOX, he developed lung metastases confirmed by imaging and biopsy.
Key developments include:
[Problem Comments]
Problem 1. Pulmonary Nodules - Metastatic Colorectal Adenocarcinoma
Problem 2. Tumor Marker Trends - CEA and CA-199
Problem 3. Hepatic Cysts and Liver Status
Problem 4. HBV Reactivation Risk
Problem 5. Ongoing Systemic Therapy - Tolerance and Management
Comprehensive Follow-Up
[IHC and Molecular Profiling for CRC Therapy]
IHC Results and Their Clinical Implications
Targeted Therapy and Immunotherapy Selection
Recommendations
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
[Summary]
The patient, a 54-year-old woman with bilateral high-grade serous ovarian carcinoma (pT3bNx, FIGO Stage IIIB), recently initiated first-line chemotherapy with Paclitaxel + Carboplatin on 2025-02-10. She underwent laparoscopic bilateral salpingo-oophorectomy on 2025-01-22, followed by Port-A implantation on 2025-01-24. Imaging (CT 2025-01-24) confirmed peritoneal carcinomatosis with mesenteric and retroperitoneal lymphadenopathy.
Laboratory trends indicate:
She also has chronic viral hepatitis B (HBsAg-negative, Anti-HBc-positive) and is now on Vemlidy (tenofovir alafenamide) to prevent HBV reactivation.
[Problems]
Problem 1. High-Grade Serous Ovarian Carcinoma (FIGO IIIB, pT3bNx)
Problem 2. Chemotherapy-Associated Hematologic and Organ Function Monitoring
Problem 3. Chronic Hepatitis B with Chemotherapy-Induced Reactivation Risk
[exam finding]
[MedRec]
[consultation]
[medication]
The 83-year-old male patient has advanced left lung adenocarcinoma (EGFR mutation: exon 19 deletion, stage IVB) with confirmed metastases to the liver and suspected metastases to the brain and bone. He also has a history of diffuse large B-cell lymphoma (DLBCL) treated with splenectomy and R-COP chemotherapy, along with comorbidities of type 2 diabetes mellitus, essential hypertension, hyperlipidemia, chronic viral hepatitis B, and idiopathic gout. His current admission (2025-02-06) is primarily for pneumonia in the left lung, presenting with dyspnea and thick sputum. Lab results reveal hyperuricemia and mild renal impairment. The patient’s treatment includes oxygen support, antibiotics, and medications to manage hyperuricemia and respiratory symptoms, while Tagrisso (osimertinib) has been temporarily held due to pneumonia.
Problem 1. Pneumonia in the Left Lung
Problem 2. Hyperuricemia
Problem 3. Mild Renal Impairment
Problem 4. Advanced Left Lung Adenocarcinoma with Metastases
[Proposed Improvements for Treatment, Medication Regimens, and Supportive Care Strategies] (just for reference, not posted)
A. Treatment Plan Adjustments
B. Medication Regimen Adjustments
C. Supportive Care Enhancements
D. Summary of Key Recommendations
| Category | Current Approach | Proposed Improvement |
|---|---|---|
| Targeted Therapy | Osimertinib monotherapy | Add carboplatin + pemetrexed combination (if feasible after pneumonia resolution). |
| Second-Line Treatment | No changes yet | If progression, re-biopsy for resistance mutations. If needed, switch to Amivantamab-vmjw + carboplatin + pemetrexed. |
| Pneumonia Management | Levofloxacin 750 mg IV | Consider broader coverage or antifungal if no response. Monitor oxygenation closely. |
| Hyperuricemia | Febuxostat + Sodium Bicarbonate | Increase hydration, titrate sodium bicarbonate, monitor response. |
| Respiratory Support | Inhalers + acetylcysteine | Consider nebulized hypertonic saline or short-course steroids for symptom relief. |
| Nutritional Support | No interventions documented | Consider nutritional counseling and supplements for cachexia prevention. |
| Palliative Care | No engagement documented | Initiate discussions for pain and psychological support. |
[Key Findings and Analysis]
Clinical Context
Imaging and Pathology
Symptoms and Drug History
The patient reports worsening dyspnea, which may be attributed to:
Hyperkalemia (serum K+ 5.3 mmol/L on 2024-11-25), which could worsen dyspnea and requires management.
Hyperglycemia and proteinuria are noted, possibly linked to diabetes or malignancy-related renal dysfunction.
Recommendations for Management
[exam finding]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
The patient is a 76-year-old female with advanced rectal cancer (cT4aN2aM0, stage IIIC) status post transverse loop colostomy (2024-10-23) and Port-A implantation (2024-11-07). She has undergone chemoradiotherapy (CCRT with 5-FU x2 and FOLFOX since 2025-01-10) and pelvic radiotherapy (45 Gy/25 fx completed on 2024-12-20). Comorbidities include rheumatoid arthritis, hypertension, and hepatitis B (carrier, on Baraclude [entecavir]). Her current admission (2025-02-06) is for C2D1 FOLFOX Q2W chemotherapy. She is clinically stable, ECOG PS 1, with mild anemia, normal renal and liver function, and no acute symptoms post-chemotherapy.
Problem 1. Advanced Rectal Cancer (cT4aN2aM0, stage IIIC)
Problem 2. Mild Anemia
Problem 3. Viral Hepatitis B Carrier Status
Problem 4. Hypertension
Problem 5. Rheumatoid Arthritis
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
Granocyte (lenograstim 250ug) CGRAN01 (not completed)
Since last review on 2024-12-17, the patient with advanced pancreatic neck adenocarcinoma (cT4N1M0, stage III) has undergone continued chemotherapy with Gemzar (gemcitabine) and Abraxane (nab-paclitaxel), adjusted for bone marrow suppression. Notable clinical developments include:
Problem 1. Pancreatic Neck Adenocarcinoma, cT4N1M0, Stage III
Problem 2. Anemia
Problem 3. Hypoalbuminemia
Problem 4. Electrolyte Imbalances
[Later-line Treatment Options]
Systemic Therapy Options as Later-line Treatment
Rationale for Avoiding Gemcitabine Rechallenge
Supportive and Adjunctive Therapies
[recurrent neutropenia]
This patient demonstrates recurrent neutropenia associated with chemotherapy for advanced pancreatic adenocarcinoma, complicated by significant disease burden and comorbidities.
Observations
Summary
Recommendations
[Findings and Recommendations]
This patient, a 74-year-old male with a history of adenocarcinoma of the pancreatic neck, cachexia, type 2 diabetes mellitus, chronic hepatitis B, and hypertension. He has undergone liver transplantation and is currently receiving chemotherapy for pancreatic cancer.
Vital Signs and Laboratory Findings
Imaging Findings
Medication Review and Adjustments
Recommendations
[Evaluation of Delayed Gastric Emptying and Management Plan]
Exam results from a gastric emptying study, upper GI series, and EGD (2024-08-20 to 2024-08-22) show clear evidence of delayed gastric emptying (T1/2 = 148.59 minutes), likely due to multiple factors:
Management Considerations:
[Lab Results Overview: electrolyte imbalances and anemia management]
The recent lab results indicate hypokalemia with potassium at 3.1 mmol/L, low albumin at 3.0 g/dL, and low magnesium at 1.8 mg/dL. Hemoglobin (HGB) is also low at 8.5 g/dL, reflecting anemia. The CRP level, at 4.9 mg/dL, suggests an inflammatory response. Potassium and magnesium supplementation have already been initiated, and an LPRBC transfusion was performed to address the anemia. Blood glucose levels are currently well-controlled. Medication reconciliation found no discrepancies.
[Certican (everolimus) blood level monitoring]
Background:
Interpretation:
Recommendation:
[reconcilation]
The patient had an appointment at Tri-Service General Hospital on 2023-09-23 and received prescriptions for Trajenta (linagliptin), Diovan (valsartan), Certican (everolimus), and Stilnox (zolpidem), with the latter not currently being utilized. Please verify if the discontinuation of Stilnox is intentional.
As an additional note, the patient received an injection of Zoladex (goserelin acetate) at TSGH on 2023-10-06, with the previous injection administered on 2023-07-28.
This patient had an appointment at the Tri-Service General Hospital on 2023-06-24 where he was prescribed Trajenta (linagliptin), Diovan (valsartan), Certican (everolimus), and Stilnox (zolpidem). These medications have been correctly incorporated into the patient’s active medication list. No discrepancies were found during the medication reconciliation process.
This patient had an appointment at the Tri-Service General Hospital on 2023-05-05, during which he was prescribed a single dose of Zoladex (goserelin acetate 10.8mg). As the suggested administration interval for this medication is every 12 weeks, the next scheduled dose should be on 2023-07-28. No issues were discovered during the medication reconciliation process.
The patient seems to be showing signs of anemia with an increasing trend towards macrocytosis. As the bilirubin level is still within the normal range, hemolytic anemia may be less likely. A single intramuscular dose of B-Red (hydroxocobalamin 1mg) is scheduled for 2023-06-02, and folate is already included in the current FOLFIRINOX regimen. At this time, there is no concrete evidence indicating a rapid progression in the severity of anemia, so please continue monitoring.
Zoladex (goserelin acetate) 10.8mg was administered Q3M, with the most recent administration occurring on 2023-05-05, at TSGH for the management of the patient’s prostate cancer. Furthermore, antiglycemic, antihypertensive, and anti-rejection medications prescribed at TSGH are correctly reflected in the current active medication list, presenting no issues with medication reconciliation.
Please be aware, there is a slow yet noticeable upward trend in both AST and ALT lab results. This should be closely monitored for possible potential liver function impairment.
2023-05-10 S-GOT/AST 35 U/L
2023-04-25 S-GOT/AST 42 U/L
2023-04-11 S-GOT/AST 30 U/L
2023-03-28 S-GOT/AST 25 U/L
2023-03-23 S-GOT/AST 30 U/L
2023-03-09 S-GOT/AST 23 U/L
2023-02-22 S-GOT/AST 17 U/L
2023-02-15 S-GOT/AST 16 U/L
2023-01-30 S-GOT/AST 14 U/L
2023-01-13 S-GOT/AST 19 U/L
2023-05-10 S-GPT/ALT 44 U/L
2023-04-25 S-GPT/ALT 55 U/L
2023-04-11 S-GPT/ALT 36 U/L
2023-03-28 S-GPT/ALT 32 U/L
2023-03-23 S-GPT/ALT 35 U/L
2023-03-09 S-GPT/ALT 27 U/L
2023-02-22 S-GPT/ALT 21 U/L
2023-02-15 S-GPT/ALT 22 U/L
2023-01-30 S-GPT/ALT 20 U/L
2023-01-13 S-GPT/ALT 20 U/L
[exam finding]
[MedRec]
[surgical operation]
[immunochemotherapy]
2025-02-03 - irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 540mg NS 250mL 2hr + fluorouracil 300mg/m2 540mg D5W 250mL 10min + fluorouracil 2400mg/m2 4300mg D5W 500mL 46hr (FOLFIRI)
2025-01-10 - irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 540mg NS 250mL 2hr + fluorouracil 300mg/m2 540mg D5W 250mL 10min + fluorouracil 2400mg/m2 4300mg D5W 500mL 46hr (FOLFIRI)
2024-12-20 - irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 540mg NS 250mL 2hr + fluorouracil 300mg/m2 540mg D5W 250mL 10min + fluorouracil 2400mg/m2 4300mg D5W 500mL 46hr (FOLFIRI)
2024-11-29 - irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 300mg/m2 530mg NS 250mL 2hr + fluorouracil 300mg/m2 530mg D5W 250mL 10min + fluorouracil 2400mg/m2 4300mg D5W 500mL 46hr (FOLFIRI)
2024-11-11 - irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (FOLFIRI)
2024-10-14 - irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (FOLFIRI)
2024-09-18 - irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (FOLFIRI)
2024-09-02 - irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (FOLFIRI)
2024-08-16 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (Avastin + FOLFIRI)
2024-07-29 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (Avastin + FOLFIRI)
2024-07-10 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (Avastin + FOLFIRI)
2024-06-19 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (Avastin + FOLFIRI)
2024-05-31 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (Avastin + FOLFIRI)
2024-05-17 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (Avastin + FOLFIRI)
2024-04-25 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (Avastin + FOLFIRI)
2024-04-10 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (Avastin + FOLFIRI)
2024-03-21 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (Avastin + FOLFIRI)
2024-03-05 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (Avastin + FOLFIRI)
2024-02-15 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg D5W 250mL 10min + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (Avastin + FOLFIRI)
2024-01-31 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr ……………………………………… + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (Avastin + FOLFIRI)
2024-01-12 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 150mg/m2 250mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr ……………………………………… + fluorouracil 2400mg/m2 4000mg D5W 500mL 46hr (Avastin + FOLFIRI)
2023-12-29 - (Avastin + FOLFIRI) Xia He Xiong
2023-12-11 - (Avastin + FOLFIRI) Xia He Xiong
2023-11-21 - (Avastin + FOLFIRI) Xia He Xiong
2023-11-01 - (Avastin + FOLFIRI) Xia He Xiong
2023-10-13 - (Avastin + FOLFIRI) Xia He Xiong
2023-09-22 - (FOLFIRI) Xia He Xiong
2023-09-01 - (FOLFIRI) Xia He Xiong
2023-08-22 - (FOLFOX) Chen XinHong
2023-08-07 - (FOLFOX) Xiao GuangHong
2023-07-24 - (FOLFOX) Xiao GuangHong
2023-07-10 - (FOLFOX) Xiao GuangHong
2023-06-26 - (FOLFOX) Xiao GuangHong
2023-06-12 - (FOLFOX) Xiao GuangHong
2023-05-29 - (FOLFOX) Xiao GuangHong
This 50-year-old man has advanced sigmoid cancer (pT4bN1bM1a, stage IVA) with metastases to the lungs. His disease was initially treated with surgery (T-loop colostomy, sigmoid colectomy, and small bowel resection in 2023), followed by adjuvant chemotherapy (FOLFOX) and subsequent chemotherapy (FOLFIRI ± Avastin (bevacizumab)). Imaging has demonstrated stable lung nodules without evidence of progression (CT 2025-01-11), suggesting disease control. His performance status remains ECOG 1, and he tolerates chemotherapy without significant adverse events. Supportive care measures, including antiemetics and hydration, have effectively managed side effects. The presence of a growing right renal cyst and a ventral hernia is noted but does not currently compromise his clinical condition.
Treatments and Their Effects
Recommendations for Improvement
[exam findings]
[MedRec]
[consultation]
[surigcal operation]
[immunochemotherapy]
2025-02-04 - Herceptin (trastuzumab) 600mg SC 5min
2025-01-03 - Herceptin (trastuzumab) 600mg SC 5min
2024-12-06 - Herceptin (trastuzumab) 600mg SC 5min
2024-11-12 - Herceptin (trastuzumab) 600mg SC 5min
2024-10-09 - Herceptin (trastuzumab) 600mg SC 5min
2024-09-09 - Herceptin (trastuzumab) 600mg SC 5min
2024-08-15 - docetaxel 75mg/m2 140mg NS 250mL 2hr + carboplatin AUC 5 675mg NS 250mL 2hr + Herceptin (trastuzumab) 600mg SC (TCH)
2024-07-20 - docetaxel 75mg/m2 140mg NS 250mL 2hr + carboplatin AUC 5 675mg NS 250mL 2hr + Herceptin (trastuzumab) 600mg SC (TCH)
2024-06-21 - docetaxel 75mg/m2 140mg NS 250mL 2hr + carboplatin AUC 5 675mg NS 250mL 2hr + Herceptin (trastuzumab) 600mg SC (TCH)
2024-05-25 - docetaxel 75mg/m2 140mg NS 250mL 2hr + carboplatin AUC 5 675mg NS 250mL 2hr + Herceptin (trastuzumab) 600mg SC (TCH)
2024-04-26 - docetaxel 75mg/m2 140mg NS 250mL 2hr + carboplatin AUC 5 675mg NS 250mL 2hr + Herceptin (trastuzumab) 600mg SC (TCH)
2024-04-02 - docetaxel 75mg/m2 140mg NS 250mL 2hr + carboplatin AUC 5 675mg NS 250mL 2hr + Herceptin (trastuzumab) 600mg SC (TCH)
2024-03-11 - docetaxel 75mg/m2 140mg NS 250mL 2hr + carboplatin AUC 5 675mg NS 250mL 2hr + Herceptin (trastuzumab) 600mg SC (TCH)
2023-06-05 - Herceptin (trastuzumab) 600mg SC (adjuvant)
2023-05-10 - Herceptin (trastuzumab) 600mg SC (adjuvant)
2023-04-12 - Herceptin (trastuzumab) 600mg SC (adjuvant)
2023-03-16 - Herceptin (trastuzumab) 600mg SC (adjuvant)
2023-02-22 - Herceptin (trastuzumab) 600mg SC (adjuvant)
2023-01-30 - Herceptin (trastuzumab) 600mg SC (adjuvant)
2022-12-30 - Herceptin (trastuzumab) 600mg SC (adjuvant)
2022-12-08 - Herceptin (trastuzumab) 600mg SC (adjuvant)
2022-11-18 - Herceptin (trastuzumab) 600mg SC (adjuvant)
2022-10-18 - Herceptin (trastuzumab) 600mg SC (adjuvant)
2022-09-27 - Herceptin (trastuzumab) 600mg SC (adjuvant)
2022-09-06 - Herceptin (trastuzumab) 600mg SC (adjuvant)
2022-08-16 - Herceptin (trastuzumab) 600mg SC (adjuvant)
2022-06-29 - Nolbaxol (docetaxel) 75mg/m2 140mg 1hr + Herceptin (trastuzumab) 600mg SC (neoadjuvant)
2022-06-10 - Nolbaxol (docetaxel) 75mg/m2 140mg 1hr + Herceptin (trastuzumab) 600mg SC (neoadjuvant)
2022-05-16 - Nolbaxol (docetaxel) 75mg/m2 140mg 1hr + Herceptin (trastuzumab) 600mg SC (neoadjuvant)
2022-04-22 - Nolbaxol (docetaxel) 75mg/m2 140mg 1hr + Herceptin (trastuzumab) 600mg SC (neoadjuvant)
2022-04-01 - Adriamycin (doxorubicin) 60mg/m2 110mg 10min + Endoxan (cyclophosphamide) 600mg/m2 1100mg 1hr
2022-03-11 - Adriamycin (doxorubicin) 60mg/m2 110mg 10min + Endoxan (cyclophosphamide) 600mg/m2 1100mg 1hr
2022-02-15 - Adriamycin (doxorubicin) 60mg/m2 110mg 10min + Endoxan (cyclophosphamide) 600mg/m2 1100mg 1hr
2022-01-25 - Adriamycin (doxorubicin) 60mg/m2 110mg 10min + Endoxan (cyclophosphamide) 600mg/m2 1100mg 1hr
[medication]
Lab results on 2024-05-24 were grossly normal and TPR readings during this hospitalization appear to be stable. No medication discrepancies were identified after review of HIS5 and PharmaCloud database.
[monitoring elevated glucose and lipid levels]
The patient exhibited elevated levels of blood lipids and serum glucose. Regular monitoring is advised to determine if any intervention is necessary.
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
This 64-year-old woman, diagnosed with postmenopausal invasive ductal carcinoma of the left breast (ER+, PR-, HER2-, Ki67: 15%, pT2N0M0, stage IIA) post-total mastectomy (2024-08-01), presents with low back pain for one month, progressing over two days, and associated with suspected L4 compression fracture and subacute compression fractures (MRI 2025-01-27). She has received adjuvant chemotherapy with a TC regimen, most recently on 2024-12-20. Imaging (bone scan 2025-01-15) raises concerns about potential bone metastases, degenerative joint disease (DJD), or other etiologies. She is being managed conservatively due to the high infection risk following chemotherapy.
Problem 1. Bone Metastases vs. Degenerative Bone Disease
Problem 2. Breast Cancer Progression
Conclusion:
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
2023-12-22 ~ 2024-01-26 - 4000cGy/20 fractions of the right upper gingiva and hard palate tumor bed, hypopharyngeal and esophageal tumor lesions, and 5000cGy/25 fractions of the right upper gingiva and hard palate tumor bed.
2013-12-17 ~ 2014-02-14 - 5000cGy/25 fractions of the oral tongue to bilateral neck area, 6000cGy/30 fractions of the right lateral tongue tumor tumor bed, and 6600cGy/33 fractions of the reduced tumor bed area.
[chemotherapy]
The patient is a 70-year-old individual with recurrent squamous cell carcinoma (SCC) of the right hard palate (pT4aNxaNx, cM0, Stage IVA) post wide excision and prior radiotherapy and chemotherapy. He also has a history of multiple malignancies, including SCC of the tongue and esophagus, and multiple prior treatments, including surgeries, radiotherapy, and chemotherapy. His clinical status on 2025-02-05 remains stable, with ECOG PS 1, clear consciousness, and no significant complaints such as nausea, vomiting, diarrhea, or fatigue. Active chemotherapy (PF4 regimen) with supportive care continues.
Problem 1. Recurrent squamous cell carcinoma of the right hard palate
Problem 2. Organ function and chemotherapy tolerance
Problem 3. Electrolyte imbalance (hypomagnesemia)
Problem 4. Hematologic problem: Mild anemia
Additional Recommendations:
[exam finding]
2025-02-04 KUB
2025-01-23 KUB
2025-01-23 CXR
2025-01-09, -01-02 KUB
2024-12-28 KUB
2024-12-28 CXR
2024-12-20 SONO - abdomen
2024-12-10 Patho - hemorrhoids
2024-11-22 KUB
2024-11-20 Small Intestine Series
2024-11-18 CXR
2024-11-15 CT - abdomen
2024-11-10 KUB
2024-11-10 ECG
2024-10-21 Patho - stomach biopsy
2024-10-21 Esophagogastroduodenoscopy, EGD
2024-09-27 Anoscopy
2024-08-07 MRI - liver, spleen
2024-08-06 PET
2024-07-18 ECG 24hr
2024-07-18 CT - abdomen
2024-05-23 2D transthoracic echocardiography
2024-03-19 CT - abdomen
2024-03-08 Anoscopy
2024-01-08 Patho - gallbladder
2023-12-21 Patho - duodenum biopsy
2023-12-21 Patho - pancreas biopsy
2023-12-20 Endoscopic ultrasound, EUS
2023-12-18 Percutaneous Transhepatic Gallbladder Drainage, PTGBD
2023-12-16 MRI - pancreas
2023-12-12 CT - abdomen
2023-11-20 2D transthoracic echocardiography
2023-10-25 ECG
2023-09-19 Anoscopy
2023-09-06 CXR
2023-09-04 Patho - lung wedge biopsy
2023-09-04 CXR
2023-09-01 SONO - abdomen
2023-08-24 Flow Volume Chart
2023-08-23 CT - chest
2023-07-31 CT - abdomen
2023-05-19 Patho - prostate radical resection
2023-05-03 2D transthoracic echocardiography
2023-04-19 Tc-99m MDP bone scan
2023-04-10 Patho - prostate needle biopsy
2023-04-10 Patho - prostate needle biopsy
2023-03-20 MRI - prostate
2023-02-25 CT - abdomen
2023-01-13 L-spine flex & ext (including sacrum)
2022-11-04 CT - abdomen
2022-07-14 CT - abdomen
2022-03-18 CT - abdomen
2022-01-03 Patho - tendon/tendon sheath
2021-12-10 CT - abdomen
2021-09-01 Patho - interveterbral disc
2021-08-30 Ben densitomerty - spine
2021-08-27 MRI - L-spine
2021-08-13 CT - abdomen
2021-05-16 CT - abdomen
2021-04-23 CT - abdomen
2021-04-23 Bladder Sonography
2021-04-06 Pathology - soft tissue debridement
2021-03-02 Patho - bone marrow biopsy
2021-02-01 CXR
2021-01-15 CT - abdomen
2020-11-18 Ascites Tapping
2020-11-18 SONO - abdomen
2020-10-27 KUB
2020-10-23 Bladder Sonography
2020-10-14 2D transthoracic echocardiography
2020-10-08 Patho - bone marrow biopsy
2020-10-05 SONO - abdomen
2020-09-28 Patho - lymphnode biopsy
2020-09-22 Aspiration cytology - lymph node
2020-09-22 Pathology - lymphnode biopsy
2020-09-22Endoscopic Ultrasonography, EUS
2020-09-21 MRI - upper abdomen
2020-09-21 Sonography - abdomen
2020-07-17 SONO - head and neck
2020-06-29 SONO - head and neck
2020-06-18 Esophagogastroduodenoscopy, EGD
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
This is a 75-year-old male with a complex medical history including pancreatic cancer (cT4N1M0, stage III, portal vein involvement), prostate adenocarcinoma (Gleason score 4+5=9, pT3aN0R1, stage IIIC), peripheral T-cell lymphoma (stage IV with bone marrow involvement), and adenocarcinoma of the right lung (pT1bN0M0, stage IA2). He also has ulcerative colitis, chronic hepatitis B, type 2 diabetes mellitus, hypertensive heart disease, and antiphospholipid syndrome. Recent complaints include general weakness, poor intake due to abdominal pain, intermittent hematochezia, and worsening dyspnea. Significant findings include normocytic anemia (Hgb 8.0 g/dL on 2025-02-04), hypoalbuminemia (2.8 g/dL on 2025-02-04), mild CRP elevation (2.7 mg/dL), stool retention (KUB 2025-02-04), and ongoing ulcerative colitis. Treatment includes parenteral nutrition, antibiotics, and diuretics.
Problem 1. General Weakness, Suspect Related to Poor Intake
Problem 2. Ulcerative Colitis with Abdominal Pain and Hematochezia
Problem 3. Anemia (Normocytic) and Thrombocytopenia
Problem 4. Electrolyte Imbalance
Problem 5. Multiple Cancers with Current Treatment
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
Patient Summary
The patient is a 56-year-old woman diagnosed with endometrioid carcinoma (pT1bN0, if cM0, stage IB; 2023 FIGO Stage IICm, p53abn) based on staging surgery performed on 2024-10-28. The pathology showed myometrial invasion >50%, lymphovascular invasion, but no lymph node metastasis (0/35), perineural invasion present, and no omental spread.
She has undergone RT (4500cGy/25 fractions pelvic area + 1200cGy/3 fractions vaginal cuff mucosa) completed on 2025-01-23 and three cycles of chemotherapy with Taxol (paclitaxel) and Carboplatin on 2024-11-26, 2024-12-22, and 2025-01-12, with C4 scheduled on 2025-02-04.
Comorbidities include pre-diabetes mellitus (diet-controlled for 3-4 years) and chronic viral hepatitis B (anti-HBc positive, HBsAg nonreactive). No signs of hepatic decompensation.
Recent lab results on 2025-02-03 show mild anemia (Hgb 9.0 g/dL) and thrombocytopenia (PLT 113 x10^3/uL) with stable renal and liver function. Historical trends suggest chemotherapy-related cytopenia.
Problem 1. Anemia
Problem 2. Thrombocytopenia
Problem 3. Chronic Viral Hepatitis B
Problem 4. Cancer Treatment
Problem 5. Renal and Electrolyte Balance
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
TPF regimen (in-hospital Chemotherapy Regimens for Head and Neck Cancer: Collection as of 2022-02-11) - Neoadjuvant Chemotherapy regimen
[Summary]
The patient is a 49-year-old individual with left lip and left buccal squamous cell carcinoma, ypT4aN0M0, stage IVA, complicated by bone metastases (L4 vertebra, left pubic bone) and intracranial invasion. The patient has undergone multiple surgical interventions, including wide excision, free flap reconstruction, and radical neck dissection, and has been receiving systemic chemotherapy and targeted therapy since 2022-10. Currently admitted for chemotherapy with Methotrexate/Leucovorin/Fluorouracil (MTXFL) C1D15 (2025-02-03).
Significant findings include persistent leukocytosis (27.33 x10³/uL) with an elevated CRP (12.1 mg/dL) (CBC 2025-02-03), mild anemia (Hgb 9.6 g/dL) (CBC 2025-02-03), hyponatremia (Na 127 mmol/L) (BMP 2025-02-03), and recent MRI evidence of tumor progression with intracranial invasion (MRI 2025-01-16). Renal function is stable (eGFR 81.58 mL/min/1.73m²) (BMP 2025-02-03), but the patient has chronic kidney disease (CKD stage 3) and hypomagnesemia as comorbidities.
Persistent intermittent fever for the past two weeks, possibly related to infection or tumor-related inflammation, is being managed with empirical cefuroxime therapy (Cefuroxime 1500 mg Q8H) (2025-02-03).
[Problems]
Problem 1. Advanced Squamous Cell Carcinoma with Progression
Problem 2. Leukocytosis and Possible Infection
Problem 3. Electrolyte Imbalance (Hyponatremia, Hypomagnesemia)
There was a gap in follow-up from early 2022-12 to mid 2023-03. The recommended dose of docetaxel and cisplatin in the TPF regimen for head and neck cancer, as listed in the in-hospital collection of chemotherapy regimens as of 2022-02-11, was 40mg/m2 for both drugs. However, the actual administered doses of the two drugs ranged from 50mg to 80mg. For fluorouracil, except for the first 2 doses at 4000mg, all other administrations since 2022-11 were at 3000mg.
If the patient’s dyspnea occurred on 2023-04-06 or 2023-04-07, the TPF dose administered on 2023-04-06 (the 7th dose) was docetaxel 60mg, cisplatin 60mg, and fluorouracil 3000mg all at a reduced amount, which might be less likely to cause dose-dependent adverse reactions. Is it possible that the patient experienced an infusion reaction? If this possibility cannot be ruled out, it may be worth trying a slower infusion rate or adding famotidine 20mg IVD as part of premedication in the next administration.
[exam finding]
[MedRec]
2024-12-10 ~ 2024-12-24 POMR Family Medicine Shen MingChang
2024-11-14 ~ 2024-11-19 POMR Hemato-Oncology Lin YiTing
2022-11-22 ~ 2022-12-03 POMR Hemato-Oncology Zhang ShouYi
The patient presents with multiple concerns including organ dysfunction, hematological abnormalities, electrolyte imbalances, signs of inflammation, and a history of GI and hematologic conditions. Key findings include:
Problem 1. Renal Dysfunction
Problem 2. Inflammatory State
Problem 3. Hematological Abnormalities
Problem 4. Electrolyte Imbalances
[exam finding]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
The patient, a 74-year-old female with a history of squamous cell carcinoma of the right lateral tongue border (cT4aN2cM0, Stage IVA), systemic lupus erythematosus (SLE), hypertension, and type 2 diabetes mellitus, presents with leukocytosis (WBC: 17.68 ×10^3/μL, 2025-02-03) and fatigue. Her ECOG PS is 4, indicating a poor functional status. Historical data reveals prior treatment for tongue cancer (surgery, radiotherapy), lung metastasis, and pneumonia. Current imaging and lab findings suggest ongoing systemic issues that require a multi-system approach to evaluate hematological abnormalities, organ function, and potential underlying infections or malignancy progression.
Problem 1. Leukocytosis
Problem 2. Anemia
Problem 3. ECOG PS 4 with Fatigue
Problem 4. Organ Function (Kidney and Liver)
Problem 5. Infection Risk
[exam finding]
[MedRec]
[surgical operation]
[chemotherapy]
Key Findings Since 2025-01-08:
Problem 1: Pancreatic ductal adenocarcinoma with liver metastases
Problem 2: Chemotherapy-induced anemia
Problem 3: Pancreatic pseudocyst
[Patient Summary]
The patient is a 66-year-old male diagnosed with pancreatic ductal adenocarcinoma with hepatic metastases (stage IV, cT2N0M1) based on clinical, imaging, and histopathological evidence.
Current treatment includes FOLFIRINOX chemotherapy, reduced to 90% dose due to previous tolerability and patient condition.
Other comorbidities include type 2 diabetes mellitus, coronary artery disease, benign prostatic hyperplasia, and chronic viral hepatitis B.
Monitoring of chemotherapy effects, glucose levels, and vital parameters is ongoing. Recent blood glucose readings (2025-01-07, 2025-01-08) suggest suboptimal glycemic control.
[Problem Comments]
Problem 1: Pancreatic ductal adenocarcinoma with hepatic metastases
Problem 2: Type 2 diabetes mellitus
Problem 3: Coronary artery disease and cardiovascular risk management
Problem 4: Chronic viral hepatitis B
Problem 5: Hyperlipidemia
[exam findings]
, EGD - Findings - Esophagus - Minimal mucosa break<5mm was noted at EC junction. - Stomach - Erythematous change of gastric mucosa was found. - Two ulcer scars were noted at prepyloric antrum, LC and lower body, GC, respectively. - Small grey-white, slightly elevated plaques surrounded by mixed patchy pink and pale areas of mucosa causing an irregular, uneven surface were noted at antrum, low body to angle. - Duodenum - A subepithelial lesion was noted at duodenal SDA, AW side. - Others - There was a hugh ulcer with clean base at right posterior hypopharyngeal wall. - Diagnosis: - Right posterior hypopharyngeal wall ulcer - Reflux esophagitis LA Classification grade A (minimal) - R/O gastric intestinal metaplasia, antrum, low body to angle - Superficial gastritis - Gastric ulcer scars, prepyloric antrum, LC and lower body, GC, respectively - Duodenal SEL, SDA, AW - CLO test: not done
2024-03-21 CTA - brain (head, neck)
2024-03-21 CXR
2023-12-28 ECG
2023-11-16
2023-11-01 MRI - larynx
2023-10-24 Patho - stomach biopsy
2023-10-23 CT - neck
2023-10-23 SONO - abdomen
2023-10-23 EGD
2023-10-20 PET
2023-10-19 Patho - gingival/oral mucosa biopsy
2023-10-19 Nasopharyngoscopy
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
[steps for delivering OxyNorm IR capsules via feeding tubes]
When administering OxyNorm (oxycodone) Immediate Release capsules through a nasogastric or gastrostomy tube, begin by flushing the tube with water. Open the capsule and pour the contents directly into the tube. Follow with a 15 mL water flush, then rinse the tube at least two more times with 10 mL of water each. Milk or liquid nutritional supplements can be used as alternatives to water.
[assessing leukopenia risks beyond chemotherapy effects]
The most recent CCRT, which utilized carboplatin, concluded in late Jan / early Feb 2024.
Despite this, the patient is currently experiencing rapidly developing leukopenia, an occurrence unlikely to be induced by the CCRT due to the nearly 2-month gap since its completion.
The administration of piperacillin on 2024-03-18 at KeeLung CGMH (according to PharmaCloud database) is suspected to be a possible cause, as myelosuppression, particularly neutropenia, is a known side effect of this drug.
Should the WBC count continue to decrease, the use of G-CSF may be considered to counteract this effect.
Culture results from both sputum and urine samples collected on 2023-12-29, reported on 2024-01-01, revealed mixed normal flora and less than 1000 CFU/mL, respectively. This, along with the declining CRP level, might suggest a positive response to ongoing cefepime 2000mg Q12H therapy.
Additionally, G-CSF administered since 2023-12-28 has effectively mitigated the leukopenia.
No medication discrepancies were identified during reconciliation.
[MedRec]
[consultation]
[Radiotherapy]
2024-11-26 ~ ….-..-.. - Plan to deliver 45 Gy/ 25 fx to the pancreatic tumor, LAPs, and adjacent lymphatic drainage area.
2024-07-01 ~ 2024-08-23 - completed RT to the seminal vesicles and prostate: 52 Gy/ 26 fx. The prostate: 76 Gy/ 38 fx.
[chemotherapy]
[exam findings]
pen_spark , ARFI - Number of image frames: 12 - Parameter Value - Median: 1.57 m/s - IQR: 0.21 m/s - IQR/Median: 13.1 % - Equivalent to Metavir Score: F2 - Hepatic fibrosis degree adopted by health insurance Instrument reference value - F0： ARFI < 1.30 m/s F0： ARFI < 1.35 m/s - F1： 1.3 <= ARFI < 1.50 m/s F1： 1.35 ~ 1.66 m/s - F2： 1.5 <= ARFI < 1.81 m/s F2： 1.66 ~ 1.77 m/s - F3： 1.81 <= ARFI < 1.98 m/s F3： 1.77 ~ 1.99 m/s - F4： 1.98 <= ARFI F4： 1.99 < ARFI
[MedRec]
[consultation]
[radiotherapy]
[immunochemotherapy]
2024-11-04 ~ undergoing - Lenvima (lenvatinib 10mg) 1# QD
2024-09-26 - durvalumab 1200mg NS 500mL 1hr (Imfinzi)
2024-08-23 - durvalumab 1200mg NS 500mL 1hr (Imfinzi)
2024-07-24 - tremelimumab 300mg NS 100mL 1hr + durvalumab 1200mg NS 500mL 1hr (Imjudo + Imfinzi)
2024-06-28 - durvalumab 1200mg NS 500mL 1hr (Imfinzi)
2024-05-28 - atezolizumab 1200mg NS 250mL 30min + bevacizumab 15mg/kg 700mg NS 100mL 30min (Tecentriq + Avastin)
2024-05-07 - atezolizumab 1200mg NS 250mL 30min + bevacizumab 15mg/kg 700mg NS 100mL 30min (Tecentriq + Avastin)
2024-04-18 - atezolizumab 1200mg NS 250mL 30min + bevacizumab 15mg/kg 700mg NS 100mL 30min (Tecentriq + Avastin)
2024-03-22 - atezolizumab 1200mg NS 250mL 30min + bevacizumab 15mg/kg 700mg NS 100mL 30min (Tecentriq + Avastin)
2024-02-16 - atezolizumab 1200mg NS 250mL 30min + bevacizumab 15mg/kg 700mg NS 100mL 30min (Tecentriq + Avastin)
2024-01-19 - atezolizumab 1200mg NS 250mL 30min + bevacizumab 15mg/kg 700mg NS 100mL 30min (Tecentriq + Avastin)
2023-12-29 - atezolizumab 1200mg NS 250mL 30min + bevacizumab 15mg/kg 700mg NS 100mL 30min (Tecentriq + Avastin)
2023-11-24 - atezolizumab 1200mg NS 250mL 30min + bevacizumab 15mg/kg 700mg NS 100mL 30min (Tecentriq + Avastin)
2023-11-03 - atezolizumab 1200mg NS 250mL 30min + bevacizumab 15mg/kg 500mg NS 100mL 30min (Tecentriq + Avastin)
2023-10-13 - atezolizumab 1200mg NS 250mL 30min + bevacizumab 15mg/kg 500mg NS 100mL 30min (Tecentriq + Avastin)
2023-09-08 - atezolizumab 1200mg NS 250mL 30min + bevacizumab 15mg/kg 500mg NS 100mL 30min (Tecentriq + Avastin)
Patient Summary:
Problem 1. Recurrent HCC with Lung Metastases
Problem 2. Leukopenia and Immune Status
Problem 3. Gastrointestinal Complications
Problem 4. Electrolyte Balance and Renal Function
[potential drug-induced thrombocytopenia]
Historical lab data shows a long-term decline in platelet levels. The patient’s treatment with atezolizumab and bevacizumab overlaps with this period, so the influence of these medications cannot be ruled out. Literature reports an incidence of immune thrombocytopenia of less than 1% with atezolizumab, while bevacizumab is associated with a much higher incidence of thrombocytopenia (58%; grades 3/4: 20% to 40%).
If clinically judged to be at risk of bleeding, a platelet transfusion might be considered.
The current treatment regimen has been switched to durvalumab, which has also been reported to cause immune thrombocytopenia. Please continue to monitor platelet levels.
[exam finding]
[Nutritional Strategy for Stage G3 Chronic Kidney Disease: Parenteral Formulation Choices]
Lab Data:
Assessment and Plan:
The above formulations are still appropriate for the patient’s current renal status.
[exam finding]
[MedRec]
The patient is a 63-year-old individual with a history of chronic kidney disease (CKD, stage IV), type 2 diabetes mellitus (T2DM), chronic ischemic heart disease, and mixed hyperlipidemia. The data reflects significant issues with renal function, cardiovascular health, hematological abnormalities (anemia), and potential thyroid dysfunction. The findings also suggest signs of persistent urinary tract infections (UTIs) and possibly autoimmune thyroid disease. Key findings include:
Problem 1. Chronic Kidney Disease (CKD), Stage IV
Problem 2. Anemia
Problem 3. Iron Deficiency
Problem 4. Cardiovascular Abnormalities
Problem 5. Thyroid Disease
Problem 6. Persistent Infections (not posted)
[exam findings]
[MedRec]
[consultation]
2024-12-23 Neurology
2023-11-22 Hemato-Oncology
2023-11-13 Rehabilitation
2023-11-09 Rheumatology and Immunology
2023-11-08 Hemato-Oncology
2023-11-08 Anesthesia
2023-11-05 Neurosurgery
2023-11-05 Neurology
[medication]
ciclosporin 100mg 1# TID PO 2024-02-16 ~ IPD Thymoglobuline 150mg QD IVD 2024-02-24 ~ 2024-02-27 4D
Treatment of aplastic anemia in adults - 2024-03-21 - https://www.uptodate.com/contents/treatment-of-aplastic-anemia-in-adults
The patient, a 75-year-old female with a history of severe aplastic anemia (SAA) and hypertension, presents with pancytopenia, signs of dementia (Clinical Dementia Rating 1), and recurrent infections. Current challenges include hematological abnormalities, organ function impairment, cognitive decline, and electrolyte imbalances.
Problem 1. Severe Aplastic Anemia (SAA)
Problem 2. Cognitive Decline/Dementia
Problem 3. Infection Risk
Problem 4. Cardiovascular and Organ Function
Problem 5. Electrolyte and Metabolic Imbalances
Summary of Priorities
[Diagnosis] (not posted)
The primary diagnosis appears to be severe aplastic anemia (SAA). This diagnosis is strongly supported by the clinical and laboratory findings of pancytopenia, bone marrow hypocellularity, and recurrent infections. Below is a detailed evaluation with differential diagnoses and evidence-based reasoning.
Primary Diagnosis - Severe Aplastic Anemia (SAA)
Differential Diagnoses
Summary
[TDM: proactive reduction of ciclosporin to prevent toxicity]
Since being admitted on 2024-02-16, the patient has been on “Sandimmun Neoral (ciclosporin 100mg) 1# TID”. The trough concentration on 2024-03-05 was 290 ng/mL, and it increased to 368 ng/mL by 2024-03-13. Continuing this trend without reducing the dosage could potentially result in levels exceeding the recommended upper limit of 400 ng/mL next week. Therefore, it’s suggested to decrease the current daily dosage of 300 mg to either 250 mg or 275 mg.
[ciclosporin TDM: acceptable result despite non-ideal blood draw timing (no dosage change)]
The patient is taking Sandimmun Neoral (ciclosporin 100mg) 1# TID.
The TDM for ciclosporin on 2024-03-05 in HIS5 showed that the blood draw time was recorded as 04:21 and the drug administration time was recorded as 09:35, a difference of several hours. Ideally, the trough concentration should be drawn within half an hour before the next administration. The current value is 290 ng/mL, and it should still be within a reasonable range after about 5 hours. Therefore, there is no special dosage adjustment recommended.
Cyclosporine (ciclosporin) trough level target for aplastic anemia:
[blood transfusion safety: recognizing and preventing complications]
Hypocalcemia is observed:
Multiple transfusion complications can arise during or after a blood transfusion:
[lab data]
[exam finding]
[MedRec]
[surgical operation]
[radiotherapy]
[immunochemotherapy]
The patient is a 49-year-old woman with a history of rectal adenocarcinoma (cT3N0M0), which underwent neoadjuvant chemoradiotherapy, surgical resection, and adjuvant therapy, achieving complete remission by 2021-09-28. Metastasis to the left lower lobe of the lung (confirmed as metastatic colorectal adenocarcinoma on 2024-04-01) placed her in stage IVA. She has been receiving ongoing chemotherapy with Avastin (bevacizumab) and FOLFIRI since 2024-06-06. Laboratory results from 2025-01-21 indicate relatively stable organ function.
Problem 1. Metastatic Colorectal Adenocarcinoma
Problem 2. Uterine Myoma
Problem 3. Peritoneal Thickening
[lab results clear for Avastin + FOLFIRI treatment]
Lab results from 2024-10-04 indicate normal blood cell counts, electrolytes, and liver and kidney function. These findings suggest that there are no contraindications for the patient to proceed with Avastin + FOLFIRI treatment. No medication issues were identified.
[exam findings]
[MedRec]
[consultation]
[immunotherapy]
2024-05-03 ~ ongoing - Alecensa (alectinib 150mg) 4# BIDCC
2024-07-08 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2024-05-30 - nivolumab 3mg/kg 100mg NS 100mL 1hr
2024-05-03 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2024-04-09 - nivolumab 3mg/kg 100mg NS 100mL 1hr
2024-03-11 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2024-01-30 - nivolumab 3mg/kg 100mg NS 100mL 1hr
2024-01-05 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2023-12-06 - nivolumab 3mg/kg 100mg NS 100mL 1hr
2023-11-03 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2023-10-11 - nivolumab 3mg/kg 100mg NS 100mL 1hr
2023-09-15 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2023-08-25 - nivolumab 3mg/kg 100mg NS 100mL 1hr
2023-08-04 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2023-07-10 - nivolumab 3mg/kg 100mg NS 100mL 1hr
2023-06-13 - nivolumab 3mg/kg 100mg NS 100mL 1hr
2023-05-12 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2023-04-14 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2023-03-24 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2023-02-24 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2022-04-22 - nivolumab 3mg/kg 100mg NS 100mL 1hr
2023-03-28 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2023-03-01 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2022-02-09 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2022-01-18 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2021-12-28 - nivolumab 3mg/kg 100mg NS 100mL 1hr + ipilimumab 50mg NS 40mL 1hr (administer the two drugs 1hr apart)
2021-11-30 - pembrolizumab 200mg NS 100mL 1hr
2021-11-05 - pembrolizumab 200mg NS 100mL 1hr
2021-10-15 - pembrolizumab 200mg NS 100mL 1hr
2021-09-08 - pembrolizumab 200mg NS 100mL 1hr
2020-10 erlotinib + bevacizumab followed with nivolumab + carboplatin.
[availability of entrectinib and/or alectinib]
According to the latest National Health Insurance (NHI) Drug Reimbursement Guidelines (version dated 2023-05-23), Rozlytrek (entrectinib) is only covered when used alone in adults with ROS-1 positive locally advanced or metastatic NSCLC. Alecensa (alectinib) is covered only for first-line treatment of ALK-positive advanced NSCLC. Both are not covered for papillary renal cell carcinoma.
Both Rozlytrek (entrectinib 200mg/capsule) and Alecensa (alectinib 150mg/capsule) are available in the hospital’s inventory, so no prior authorization is required (no temporary purchase procedure is necessary). The out-of-pocket cost for the former is 1802.5 TWD (NHI price 1530 TWD) and for the latter 487.5 TWD (NHI price 390 TWD).
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemoimmunotherapy]
2025-01-20 - pembrolizumab 200mg NS 100mL 30min (Keytruda Q3W)
2024-12-26 - pembrolizumab 200mg NS 100mL 30min (Keytruda Q3W)
2024-11-29 - pembrolizumab 200mg NS 100mL 30min (Keytruda Q3W)
2024-11-19 ~ undergoing - Lenvima (lenvatinib 10mg) 1# QD
2024-11-19 ~ udnergoing - Nolvadex (tamoxifen citrate 10mg) 1# Q12H
2023-11-14 - bevacizumab 15mg/kg 650mg NS 250mL 1.5hr + paclitaxel 150mg/m2 200mg NS 250mL 3hr + carboplatin AUC 3 200mg NS 250mL 2hr (Q3W)
2023-09-18 - bevacizumab 15mg/kg 650mg NS 250mL 1.5hr
2023-08-01 - paclitaxel 175mg/m2 200mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr …………………………………… (Q3W)
2023-05-30 - paclitaxel 175mg/m2 235mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + bevacizumab 15mg/kg 650mg NS 250mL 1.5hr (Q3W)
2023-03-23 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + bevacizumab 15mg/kg 650mg NS 250mL 1.5hr (Q3W)
2023-02-24 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr + bevacizumab 15mg/kg 650mg NS 250mL 1.5hr (Q3W)
This 73-year-old female patient with a history of endometrioid adenocarcinoma (Grade 2, FIGO stage IA), initially treated with surgery and radiotherapy, has developed multiple systemic metastatic lesions, particularly in mesenteric, omental lymph nodes, and liver. Despite undergoing multiple chemotherapy, immunotherapy, and targeted therapy regimens, she now presents with stable disease in the abdomen and lymph nodes.
Problem 1: Systemic Metastatic Endometrioid Carcinoma
Problem 2. Leukopenia
Problem 3. Neuropsychiatric Symptoms (not posted)
This patient refilled Eurodin (estazolam) and Lexapro (escitalopram) on 2023-07-10 issued by our psychosomatic medicine department and these drugs have been included in the active medication list without a reconciliation issue found.
[exam finding]
The patient exhibits several abnormalities across multiple laboratory evaluations between 2025-01-15 and 2025-01-21.
Summary of Differential Diagnoses:
Immediate Recommendations:
[exam finding]
[consultation]
[surgical operation]
[chemotherapy]
2025-01-20 - carboplatin AUC 5 330mg NS 500mL 2hr + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-4 (PF Q4W)
2024-12-16 - carboplatin AUC 5 330mg NS 500mL 2hr + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-4 (PF Q4W)
2024-11-12 - carboplatin AUC 5 330mg NS 500mL 2hr + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-4 (PF Q4W)
2024-10-04 - carboplatin AUC 5 330mg NS 500mL 2hr + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-4 (PF Q4W)
2024-08-29 - carboplatin AUC 5 330mg NS 500mL 2hr + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-4 (PF Q4W)
2024-07-30 - carboplatin AUC 5 330mg NS 500mL 2hr + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-4 (PF Q4W)
2024-06-29 - carboplatin AUC 5 300mg NS 500mL 2hr + MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-4 (PF Q4W)
2024-05-24 - carboplatin AUC 5 280mg NS 500mL 2hr + MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4 (PF Q4W)
2023-12-26 ~ 2024-05-30 - UFT (tegafur 100mg, uracil 224mg) 2# BID
2023-09-13 - carboplatin AUC 2 150mg D5W 250mL 2hr + NS 1000mL 2hr (Y-sited carboplatin) (CCRT)
2023-08-31 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL 2hr (Y-sited CDDP) (CCRT)
2023-08-24 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL 2hr (Y-sited CDDP) (CCRT)
2023-08-17 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL 2hr (Y-sited CDDP) (CCRT)
2023-08-10 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL 2hr (Y-sited CDDP) (CCRT)
2023-07-27 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL 2hr (Y-sited CDDP) (CCRT)
2023-07-19 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL 2hr (Y-sited CDDP) (CCRT)
2023-06-14 - docetaxel 60mg/m2 80mg NS 250mL 1hr D1 + cisplatin 75mg/m2 100mg NS 500mL 24hr (Y-sited 5-FU) D2 + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) D2 + furosemide 20mg NS 250mL 10min (after CDDP) D2 + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D2-5 (TPF)
2023-05-19 - docetaxel 60mg/m2 80mg NS 250mL 1hr D1 + cisplatin 75mg/m2 100mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) D2 + furosemide 20mg NS 250mL 10min (after CDDP) D2 + fluorouracil 1000mg/m2 1300mg NS 500mL 24hr D1-4 (TPF)
2023-04-26 - docetaxel 60mg/m2 80mg NS 250mL 1hr D1 + cisplatin 75mg/m2 100mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) D2 + furosemide 20mg NS 250mL 10min (after CDDP) D2 + fluorouracil 1000mg/m2 1300mg NS 500mL 24hr D1-4 (TPF)
2023-03-30 - docetaxel 60mg/m2 80mg NS 250mL 1hr D1 + cisplatin 75mg/m2 100mg NS 500mL 24hr (Y-sited 5-FU) D1 …………………………………………………………………………………. + fluorouracil 1000mg/m2 1300mg NS 500mL 24hr D1-4 (TPF)
Neoadjuvant Chemotherapy regimen in In-hospital “Prescription Collection of Chemotherapy for Head and Neck Cancer” protocol (dated 2022-02-11).
Docetaxel, cisplatin and fluorouracil induction chemotherapy followed by chemoradiotherapy for locally advanced, squamous cell carcinoma of the head and neck (TAX324) 2023-04-27 https://www.uptodate.com/contents/image?imageKey=ONC%2F65438&topicKey=ONC%2F85694
Cycle length: Every 21 days for three cycles.
Regimen
Docetaxel, cisplatin, and fluorouracil induction chemotherapy followed by radiotherapy for locally advanced, squamous cell carcinoma of the head and neck (TAX323) 2023-04-27 https://www.uptodate.com/contents/image?imageKey=ONC%2F72461&topicKey=ONC%2F85694
Cycle length: Every 21 days for four cycles.
Regimen
[Summary]
[Problems]
Problem 1. Advanced Squamous Cell Carcinoma
Problem 2. Renal Impairment
Problem 3. Hematological Abnormalities
Problem 4. Chronic Hepatitis B
[macrocytic anemia]
Macrocytic anemia is present. Common etiologies include vitamin B12 and/or folate deficiency. Supplementation might be considered.
According to the PharmaCloud database, all of this patient’s prescribed medications for the past 3 months have been provided exclusively by our hospital. There are no identified medication reconciliation issues.
The leukocytosis seems to be improving as the patient’s WBC count is nearing ULN. The medications recently used, which include esomeprazole, entecavir, and megestrol, have been reviewed, but none of them are known to significantly affect the WBC count. At the moment, there don’t seem to be any medication-related problems associated with this issue.
Hypomagnesemia has been noted. This might be due to the use of the TPF regimen, which contains cisplatin, and/or the PPI, esomeprazole. During the regimen administration and hospital stay, the patient receives magnesium supplements. Given that hypomagnesemia has been persistent for several months, it may be beneficial to consider magnesium supplementation upon discharge.
[exam finding]
[MedRec]
[surgical operation]
clock position and fiberoptic light pipe was inserted in 2 oclock
position.[chemotherapy]
Systemic therapy regimens for locally advanced, potentially resectable gastric or gastro-esophageal junction adenocarcinoma: Perioperative docetaxel, oxaliplatin, fluorouracil, and leucovorin (FLOT4) - 2025-01-20 - https://www.uptodate.com/contents/image?imageKey=ONC%2F120512
Systemic therapy regimens for gastrointestinal cancer: Modified FOLFOX6 - 2025-01-20 - https://www.uptodate.com/contents/image?imageKey=ONC%2F50132
[Patient Summary]
This 73-year-old female patient presents with advanced gastric adenocarcinoma (cT3N3M1, stage IV, HER2-negative, CPS = 8) and a history of left breast cancer (initially pT1cN2aM0, stage IIIA, ER+, PR+, HER2 3+, Ki67 <10%).
She is currently undergoing palliative concurrent chemoradiotherapy (CCRT) for gastric cancer and targeted therapy for breast cancer recurrence. Her condition is complicated by chronic kidney disease (CKD stage 4), type 2 diabetes mellitus, hyperlipidemia, and a thrombotic event in the left post-tibial vein. Key challenges include balancing oncological treatment efficacy with systemic complications such as hematological issues, CKD management, and maintaining overall quality of life.
[Problem Comments]
Problem 1. Gastric Adenocarcinoma with Metastasis
Problem 2. Breast Cancer (HER2-positive)
Problem 3. Chronic Hepatitis B
Problem 4. Chronic Kidney Disease Stage 4
Problem 5. Type 2 Diabetes Mellitus (DM)
Problem 6. Hematological Problems
Problem 7. Electrolyte and Nutritional Imbalances
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
2025-01-20 - oxaliplatin 85mg/m2 50mg D5W 250mL 2hr + leucovorin 400mg/m2 180mg NS 250mL 2hr + flurouracil 2400mg/m2 1000mg D5W 500mL 24hr (FOLFOX. Oxa 30%, FL 25%)
2024-12-30 - oxaliplatin 85mg/m2 75mg D5W 250mL 2hr + leucovorin 400mg/m2 180mg NS 250mL 2hr + flurouracil 2400mg/m2 1000mg D5W 500mL 24hr (FOLFOX. Oxa 50%, FL 25%)
2024-12-02 - pembrolizumab 2mg/kg 100mg NS 100mL 1hr
2024-11-11 - pembrolizumab 2mg/kg 100mg NS 100mL 1hr + cisplatin 25mg/m2 20mg NS 500mL 2hr + MgSO4 10% 20mL KCl 15% 5mL NS 500mL 2hr + gemcitabine 1000mg/m2 900mg NS 250mL 0.5hr (Keytruda + Kemoplat + Gemzar. CDDP 50%, Gemzar 50%)
2024-10-14 - pembrolizumab 2mg/kg 100mg NS 100mL 1hr + cisplatin 25mg/m2 20mg NS 500mL 2hr + MgSO4 10% 20mL KCl 15% 5mL NS 500mL 2hr + gemcitabine 1000mg/m2 900mg NS 250mL 0.5hr (Keytruda + Kemoplat + Gemzar. CDDP 50%, Gemzar 50%)
2024-09-23 - pembrolizumab 2mg/kg 100mg NS 100mL 1hr + cisplatin 25mg/m2 20mg NS 500mL 2hr + MgSO4 10% 20mL KCl 15% 5mL NS 500mL 2hr + gemcitabine 1000mg/m2 900mg NS 250mL 0.5hr (Keytruda + Kemoplat + Gemzar. CDDP 50%, Gemzar 50%)
2024-08-26 - pembrolizumab 2mg/kg 100mg NS 100mL 1hr + cisplatin 25mg/m2 20mg NS 500mL 2hr + MgSO4 10% 20mL KCl 15% 5mL NS 500mL 2hr + gemcitabine 1000mg/m2 900mg NS 250mL 0.5hr (Keytruda + Kemoplat + Gemzar. CDDP 50%, Gemzar 50%)
2024-08-12 - ………………………………….. cisplatin 25mg/m2 23mg NS 500mL 2hr + MgSO4 10% 20mL KCl 15% 5mL NS 500mL 2hr …………………………………….. (………. Kemoplat ……… CDDP 50% ………..)
2024-07-29 - pembrolizumab 2mg/kg 100mg NS 100mL 1hr + cisplatin 25mg/m2 23mg NS 500mL 2hr + MgSO4 10% 20mL KCl 15% 5mL NS 500mL 2hr + gemcitabine 1000mg/m2 900mg NS 250mL 0.5hr (Keytruda + Kemoplat + Gemzar. CDDP 50%, Gemzar 50%)
2024-07-15 - ………………………………….. cisplatin 25mg/m2 23mg NS 500mL 2hr + MgSO4 10% 20mL KCl 15% 5mL NS 500mL 2hr + gemcitabine 1000mg/m2 900mg NS 250mL 0.5hr (………. Kemoplat + Gemzar. CDDP 50%, Gemzar 50%)
2024-07-03 - pembrolizumab 2mg/kg 100mg NS 100mL 1hr + cisplatin 25mg/m2 23mg NS 500mL 2hr + MgSO4 10% 20mL KCl 15% 5mL NS 500mL 2hr + gemcitabine 1000mg/m2 900mg NS 250mL 0.5hr (Keytruda + Kemoplat + Gemzar. CDDP 50%, Gemzar 50%)
2024-06-17 - ………………………………….. cisplatin 25mg/m2 37mg NS 500mL 2hr + MgSO4 10% 20mL KCl 15% 5mL NS 500mL 2hr + gemcitabine 1000mg/m2 900mg NS 250mL 0.5hr (………. Kemoplat + Gemzar. CDDP 80%, Gemzar 50%)
2024-06-11 - pembrolizumab 2mg/kg 100mg NS 100mL 1hr + cisplatin 25mg/m2 37mg NS 500mL 2hr + MgSO4 10% 20mL KCl 15% 5mL NS 500mL 2hr + gemcitabine 1000mg/m2 900mg NS 250mL 0.5hr (Keytruda + Kemoplat + Gemzar. CDDP 80%, Gemzar 50%)
2024-05-21 - mitomycin-C 30mg/m2 30mg BI 1hr (MMC)
2024-03-25 ~ 2024-05-13 - TS-1 (tegafur 25mg, gimeracil 7.25mg, oteracil potassium 24.5mg. 25mg) BID PO
2024-05-06 - gemcitabline 1000mg/m2 900mg NS 250mL 1hr (Gemzar + TS-1)
2024-04-22 - gemcitabline 1000mg/m2 900mg NS 250mL 1hr (Gemzar + TS-1)
2024-04-15 - gemcitabline 1000mg/m2 900mg NS 250mL 1hr (Gemzar + TS-1)
2024-04-01 - gemcitabline 1000mg/m2 900mg NS 250mL 1hr (Gemzar + TS-1)
2024-03-22 - gemcitabline 1000mg/m2 900mg NS 250mL 1hr (Gemzar + TS-1)
2023-10-24 - mitomycin-C 30mg/m2 30mg BI 1hr (MMC)
2023-10-16 - Bacillus Calmette-Guerin 1mg/m2 3mg BI 1hr (BCG)
2023-10-09 - Bacillus Calmette-Guerin 1mg/m2 3mg BI 1hr (BCG)
2023-10-02 - Bacillus Calmette-Guerin 1mg/m2 3mg BI 1hr (BCG)
2023-09-25 - Bacillus Calmette-Guerin 1mg/m2 3mg BI 1hr (BCG)
2023-08-18 - Bacillus Calmette-Guerin 1mg/m2 3mg BI 1hr (BCG)
2023-09-11 - Bacillus Calmette-Guerin 1mg/m2 3mg BI 1hr (BCG)
2023-09-01 - mitomycin-C 30mg/m2 30mg BI (bladder irrigation) 1hr (MMC)
The patient is a 59-year-old male with complex medical issues, including intrahepatic cholangiocarcinoma, HBV-related cirrhosis with portal hypertension, diabetes mellitus, and thrombocytopenia. Recent imaging (2024-12-31 SONO) suggests progressive cholangiocarcinoma in the liver (S7 lesion, 4–5 cm mass), cirrhosis-related complications (splenomegaly, ascites), and possible pleural effusion. Hematologic evaluation reveals severe thrombocytopenia (45 x 10³/uL on 2025-01-20), hypoalbuminemia, and elevated tumor markers (CEA, CA19-9). Treatment includes FOLFOX and Pembrolizumab (Keytruda), with some dose adjustments and interruptions. Glycemic control remains suboptimal (HbA1c 7.5%).
Problem 1. Thrombocytopenia
Problem 2. Intrahepatic Cholangiocarcinoma
Problem 3. Liver Cirrhosis with Portal Hypertension
Problem 4. Diabetes Mellitus
Problem 5. Dyslipidemia
Problem 6. Gallbladder Wall Edema
Problem 7. Ascites
[Thrombocytopenia]
Thrombocytopenia in this simulated patient is evident through persistently low platelet counts across multiple dates.
Evidential Review of Thrombocytopenia
Primary Considerations for Thrombocytopenia
Next Steps
[Problem List]
Problem 1. Intrahepatic Cholangiocarcinoma, cT2N0M0, Stage II
Problem 2. Liver Cirrhosis with Portal Hypertension and Splenomegaly
Problem 3. Chronic Hepatitis B Infection
Problem 4. Type 2 Diabetes Mellitus with Suboptimal Control
Problem 5. Recurrent Non-Invasive Papillary Urothelial Carcinoma, Urinary Bladder
Problem 6. Left Hydronephrosis with Double-J Stenting
Problem 7. Anemia
Problem 8. Recent Episodes of Neutropenia
Problem 9. Adverse Effects of Chemotherapy and Immunotherapy
Problem 10. Esophageal Varices
Problem 11. Gastroesophageal Reflux Disease (GERD) and Gastritis
Problem 12. Chronic Cystitis
Problem 13. Elevated Tumor Markers (CEA, CA19-9, AFP)
Problem 14. Chronic Fatigue and Nutritional Deficiencies
Problem 15. Hypermetabolic Lymph Nodes
Problem 16. Biliary Obstruction Risks
[platelet improvement noted despite thrombocytopenia risks - considering platelet transfusion for chronic low platelet counts]
In the 2024-08-27 pharmacist note, the patient’s chronic thrombocytopenia was highlighted, including the incidence of thrombocytopenia with pembrolizumab, cisplatin, and gemcitabine. If the current regimen remains unchanged, platelet transfusion could be considered to reduce the risk of bleeding.
The platelet count recently improved from 35 K/uL to 46 K/uL, showing slight improvement but still remaining below 50 K/uL.
[rising DBI/TBI ratio points to possible biliary obstruction]
Over the past month, the patient’s direct bilirubin levels have increased, along with a rise in the DBI/TBI ratio, suggesting a possible biliary obstruction. If Uliden (ursodeoxycholic acid) is ineffective in resolving the issue, surgical intervention may be eventually necessary to restore normal bile flow.
2024-09-23 Bilirubin direct 0.33 mg/dL
2024-08-26 Bilirubin direct 0.20 mg/dL
2024-07-29 Bilirubin direct 0.13 mg/dL
2024-09-23 DBI/TBI 27.27 %
2024-08-26 DBI/TBI 24.39 %
2024-07-29 DBI/TBI 20.31 %
[Long-Term Decline in Platelet Levels and Thrombocytopenia Risk]
The patient’s platelet (PLT) levels have shown a gradual decline over the past year, with all values falling below the normal range since August 2023. Initially around 50K/uL, PLT levels have frequently dropped below 40K/uL and even 30K/uL since July 2024.
Each medication in the current regimen is associated with a risk of thrombocytopenia, and it is possible that one or more of these drugs are contributing to or exacerbating the condition:
If the clinical risk of bleeding increases, platelet transfusion may be considered.
[lab data]
2024-11-16 EB VCA IgG Positive Ratio
2024-11-16 EB VCA IgG Value 4.3 Ratio
2024-11-14 EB VCA IgM Equivocal Index
2024-11-14 EB VCA IgM Value 0.9 Index
2024-11-14 Anti-HCV (NM) Negative
2024-11-14 Anti-HCV Value (NM) 0.034
2024-11-14 Anti-HBc (NM) Positive
2024-11-14 Anti-HBc Value (NM) 0.071
2024-11-14 Anti-HBs (NM) Positive
2024-11-14 Anti-HBs value (NM) 479.000 mIU/mL
2024-11-14 HBsAg (NM) Negative
2024-11-14 HBsAg Value (NM) 0.453
2024-11-14 VZV IgG Positive mIU/mL
2024-11-14 VZV-G Value 1107 mIU/mL
2024-11-13 CMV IgM Nonreactive
2024-11-13 CMV IgM Value 0.11 Index
2024-11-13 CMV_IgG Reactive
2024-11-13 CMV_IgG Value 222.0 AU/mL
2024-11-13 Anti HTLV I/II Nonreactive
2024-11-13 Anti HTLV I/II Value 0.07 S/CO
2024-11-06 RPR Nonreactive
2024-11-06 HIV Ab-EIA Nonreactive
2024-11-06 Anti-HIV Value 0.05 S/CO
2024-03-06 HLA A-high 02:03
2024-03-06 HLA A-high 33:03
2024-03-06 HLA B-high 51:01
2024-03-06 HLA B-high 58:01
2024-03-06 HLA C-high 03:02
2024-03-06 HLA C-high 14:02
2024-03-06 HLA DR-high 11:06
2024-03-06 HLA DR-high 13:02
2024-03-06 HLA DQ-high 03:01
2024-03-06 HLA DQ-high 06:09
2024-02-22 HBsAg Nonreactive
2024-02-22 HBsAg Value 0.50 S/CO
2024-02-22 Anti-HBc Nonreactive
2024-02-22 Anti-HBc Value 0.35 S/CO
2024-02-22 Anti-HCV Nonreactive
2024-02-22 Anti-HCV Value 0.06 S/CO
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[PBSCT]
[chemotherapy]
2024-11-25 - methotrexate 10mg/m2 14mg NS 100mL 1hr D1,4,8
2024-11-23 - methotrexate 15mg/m2 22mg NS 100mL 1hr
2024-11-16 - fludarabine 50mg/m2 73mg NS 100mL 1hr D1-5 + busulfan 130mg/m2 190mg NS 500mL 3hr D2-4
2024-10-11 - fludarabine 30mg/m2 43mg NS 100mL 30min D1-5 + cytarabine 2000mg/m2 2890mg NS 500mL 4hr D1-5 + idarubicin 8mg/m2 12mg NS 100mL 10min D1-3 (FLAG)
2024-08-15 - fludarabine 30mg/m2 43mg NS 100mL 30min D1-5 + cytarabine 2000mg/m2 2800mg NS 500mL 4hr D1-5 + idarubicin 8mg/m2 12mg NS 100mL 10min D1-3 (FLAG)
2024-06-13 - daunorubicin 45mg/m2 62mg NS 100mL 10min D1-2 + cytarabine 100mg/m2 139mg NS 500mL 24hr D1-5
2024-04-16 - daunorubicin 45mg/m2 60mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 132mg NS 500mL 24hr D1-7
2024-02-23 - daunorubicin 45mg/m2 60mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 137mg NS 500mL 24hr D1-7
Acute myeloid leukemia: Induction therapy in medically fit adults - 2024-10-15 - https://www.uptodate.com/contents/acute-myeloid-leukemia-induction-therapy-in-medically-fit-adults
Acute myeloid leukaemia FLAG-Ida (fludarabine cytarabine idarubicin and filgrastim) - 2024-10-15 - https://www.eviq.org.au/haematology-and-bmt/leukaemias/acute-myeloid-leukaemia/347-acute-myeloid-leukaemia-flag-ida-fludarabine
Acute myeloid leukaemia FLAG (fludarabine cytarabine and filgrastim) - 2024-10-15 - https://www.eviq.org.au/haematology-and-bmt/leukaemias/acute-myeloid-leukaemia/346-acute-myeloid-leukaemia-flag-fludarabine-cyta
[CMV Viremia in the Context of MUD Allo-PBSCT]
Lab results
Summary
[Problems]
Problem 1: Persistent CMV Viremia
Problem 2: Risk of End-Organ CMV Disease
Problem 3: Ganciclovir Toxicity Management
Final Recommendations (not posted)
[Ciclosporin Dosage Adjustment]
Based on the lab results and the target therapeutic range of 200–300 ng/mL, the following adjustments are recommended:
Step 1: Current Status
Step 2: Recommended Dosage Adjustment
Step 3: Rationale for Reduction
Step 4: Additional Considerations
[Assessment of allo-PBSCT Timing for the Patient on 2024-11-22] (not posted)
Conclusion
[Developing an appropriate dosing plan for ciclosporin A to achieve a target trough concentration of 200-300 ng/mL in this patient]
| Date | Daily Dose (mg) | Administration Route |
|---|---|---|
| 2024-12-18 | 175 mg | PO |
| 2024-12-19 | 200 mg | PO |
| 2024-12-20 | 175 mg | PO |
| 2024-12-21 | 200 mg | PO |
| 2024-12-22 | 175 mg | PO |
| 2024-12-23 | 200 mg | PO |
| 2024-12-24 | 175 mg | PO |
| 2024-12-25 | 200 mg | PO |
| 2024-12-26 | 175 mg | PO |
| 2024-12-27 | 200 mg | PO |
| 2024-12-28 | 175 mg | PO |
| 2024-12-29 | 200 mg | PO |
| 2024-12-30 | 175 mg | PO |
| 2024-12-31 | 200 mg | PO |
[Increasing Sandimmun Dose to Achieve Therapeutic Range]
Sandimmun 76 mg Q12H IVD was initiated on 2024-11-21. The cyclosporine-A trough level measured on 2024-11-25, was 97 ng/mL, which is below the target range of 100-400 ng/mL.
It is recommended to increase the dose to 80-100 mg Q12H to achieve the desired therapeutic range.
[Analysis and Recommendations for Leukopenia]
Patient History
Key Findings
Assessment of Leukopenia - Primary Causes
Management Recommendations
Prognosis (below not posted)
[early-onset thrombocytopenia linked to MDS before 7+3, following G-CSF protocol in FLAG-ida treatment]
The thrombocytopenia had developed even before the initiation of standard 7+3 and FLAG-ida treatments, with signs appearing as early as late 2023 or early 2024, likely caused by MDS RAEB-II.
For the FLAG-ida regimen, the G represents G-CSF, and it’s recommended to follow the standard protocol: Filgrastim 5 mcg/kg SC once daily from day 0 or 1 to day 5, or continue until neutrophil recovery 1. Alternatively, additional G-CSF may be administered starting 7 days after chemotherapy, until the WBC count exceeds 500/microL 2.
Ref: https://www.eviq.org.au/haematology-and-bmt/leukaemias/acute-myeloid-leukaemia/347-acute-myeloid-leukaemia-flag-ida-fludarabine https://www.uptodate.com/contents/acute-myeloid-leukemia-induction-therapy-in-medically-fit-adults
[Initiation of FLAG-ida Regimen and Neutrophil Count Trends]
The FLAG-ida regimen was initiated on 2024-08-15, and lab results showed an ANC of 966/uL with an upward trend in neutrophil count. The patient’s WBC has been consistently low for months, suggesting that this condition may not be entirely due to chemotherapy.
2024-08-16 Neutrophil 64.0 %
2024-08-10 Neutrophil 19.6 %
2024-07-18 Neutrophil 22.1 %
2024-08-16 WBC 1.51 x10^3/uL
2024-08-10 WBC 1.59 x10^3/uL
2024-07-18 WBC 3.35 x10^3/uL
2024-07-10 WBC 2.54 x10^3/uL
2024-07-08 WBC 1.75 x10^3/uL
2024-07-06 WBC 1.01 x10^3/uL
2024-07-03 WBC 0.89 x10^3/uL
2024-06-30 WBC 0.83 x10^3/uL
2024-06-27 WBC 1.02 x10^3/uL
2024-06-26 WBC 0.83 x10^3/uL
2024-06-24 WBC 1.00 x10^3/uL
2024-06-23 WBC 0.77 x10^3/uL
2024-06-21 WBC 0.67 x10^3/uL
2024-06-17 WBC 0.85 x10^3/uL
2024-06-10 WBC 2.24 x10^3/uL
2024-05-21 WBC 6.29 x10^3/uL
2024-05-13 WBC 2.24 x10^3/uL
2024-05-10 WBC 1.55 x10^3/uL
2024-05-08 WBC 0.93 x10^3/uL
2024-05-06 WBC 0.71 x10^3/uL
2024-05-04 WBC 0.84 x10^3/uL
2024-05-02 WBC 0.78 x10^3/uL
[bedside visit: patient reports improvement in leg swelling and redness]
I visited this patient around 13:40 today, who reported feeling an improvement in the redness and swelling of her legs. She relayed what our dermatologist had said, mentioning that the swollen areas would crust over. However, the patient expressed suspect about the extensive crusting, likening it to her legs undergoing a skin replacement.
The patient had no issues with other medications but remained curious about whether a specific drug could be causing these symptoms.
[ciprofloxacin: short use followed by knee pain & treatment change]
Ciprofloxacin may cause tendinopathy or rupture of tendon; Achilles is most commonly cited, but inflammation/rupture of many other tendons (including hand, rotator cuff, biceps, and thumb) has been reported.
In addition, arthropathy, or joint disease, has been observed in both animal and pediatric human studies following treatment with fluoroquinolone antibiotics, including ciprofloxacin. In an international, multicenter, randomized trial of ~700 pediatric patients (ciprofloxacin versus comparator), more patients in the ciprofloxacin group experienced musculoskeletal events both within 6 weeks and 1 year of follow-up. Arthropathy and arthralgias appear to resolve after discontinuation of treatment with no long-term sequelae. Though the true incidence is unknown, arthropathy and arthralgia are considered to be infrequent, but potentially serious adverse reactions.
Cinolone (ciprofloxacin) was used from 2024-03-07 to 2024-03-09.
On 2024-03-08, the patient reported right knee swelling, pain, and localized heat. After antibiotic therapy with ciprofloxacin. Progression of these symptoms (right knee swelling, pain, and localized heat) was observed.
On 2024-03-09, the cinolone was discontinued. Our dermatologist recommended a regimen consisting of doxycycline, prednisolone, and Topsym Cream (fluocinonide) to address these symptoms.
[bedsite visit]
Upon arrival at 11:30 on 2024-03-11, the patient had just returned to the ward from the dermatology OPD.
I saw the patient had tenderness and swelling near her right knee. There are about five red bumps, each about the size of a coin, near the right knee skin. There is also a slightly red area on her left calf skin, about 7 x 15 cm in size.
I advised her to apply the medications prescribed by our dermatologist and monitor for symptom improvement. If symptoms persist or worsen in these 2 days, further evaluation will be necessary.
[derm suspects erythematous induratum (EI) - workup for underlying cause - evaluation for tuberculosis]
During a visit to dermatology earlier today (2024-03-11), the patient was suspected to have erythematous induratum (EI).
EI is an uncommon form of panniculitis that may occur in association with tuberculosis (most common), other diseases or drugs, or as an idiopathic condition. EI is regarded as an immune-mediated hypersensitivity reaction. EI most frequently occurs in adult females. The most common clinical presentation of EI is single or multiple erythematous nodules on the posterior or lateral lower legs. Thigh and upper extremity involvement occurs occasionally. Truncal, facial, or disseminated EI is rare. Ulceration of nodules is common.
The diagnosis of EI is made based upon the presence of consistent clinical and histologic findings. Skin biopsies demonstrate a predominantly lobular panniculitis with a mixed and granulomatous inflammatory infiltrate with vasculitis. Multiple sections or multiple specimens may be required to identify vasculitis. Given the strong association of EI with tuberculosis, all patients with EI should be evaluated for tuberculosis. (Ref: https://www.uptodate.com/contents/erythema-induratum-nodular-vasculitis)
First-line treatment for nonidiopathic EI is treatment of the underlying associated disease. Nonsteroidal anti-inflammatory drugs, rest, elevation, and compression may aid with symptomatic improvement. When an underlying disease cannot be identified and treated, treatment may be challenging. Data on therapeutic options are limited. It is suggested a trial of oral potassium iodide for these patients (Grade 2C). Other treatments that may be beneficial include systemic glucocorticoids, clofazimine, colchicine, gold salts, and mycophenolate mofetil. Additional immunosuppression may not be optimal for this patients undergoing chemotherapy.
[exam findings]
[consultation]
[surgical operation]
[chemotherapy]
[Renal Function Evaluation - AKI]
Objective
Assessment
Recommendations
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
[Summary]
[Problems]
Problem 1: Rectal adenocarcinoma with liver metastases (cT3N2bM1a, Stage IVA)
Problem 2: Hematological Monitoring During Chemotherapy
Problem 3: Hepatic Function
Problem 4: Electrolyte and Nutritional Status
Problem 5: Post-surgical Recovery (2024-12-11 Partial Hepatectomy and Colostomy Closure)
[exam finding]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
[Summary]
[Problems]
Problem 1. Endometrial Serous Carcinoma
Problem 2. Bilateral Lower Limb Pitting Edema
Problem 3. Hematological Concerns
Problem 4. Hypertension
Problem 5. Electrolyte Balance (not posted)
[lab data]
2019-09-24 PD-L1 Cellblock No. S2019-14625A1
2019-09-24 PD-L1 TPS >= 1% and < 50%
2019-09-20 EGFR Cellblock No. S2019-14625A1
2019-09-20 G719X not detected 2019-09-20 Exon19 del not detected
2019-09-20 S768I not detected 2019-09-20 T790M not detected 2019-09-20
Exon20 ins not detected 2019-09-20 L858R Detected 2019-09-20 L861Q not
detected
2019-09-20 ALK IHC Cellblock No. S2019-14625A1
2019-09-20 ALK IHC Negative
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
[Patient Summary]
This simulated patient is an 81-year-old male with a history of pancreatic ductal adenocarcinoma, left upper lung adenocarcinoma, type 2 diabetes mellitus, chronic kidney disease (CKD) stage 4 (progressing from stage 3), and coronary artery disease (CAD).
The patient has undergone significant surgical procedures, including left upper lobectomy and distal pancreatectomy with splenectomy. Current evaluations highlight worsening renal function, anemia, hyperglycemia, electrolyte imbalances (notably hypokalemia), and evidence of active systemic inflammation (elevated CRP) and tumor marker progression (CEA, CA125, CA199).
[Problem Comments]
Problem 1. Renal Function Worsening (CKD Stage 4)
Problem 2. Anemia
Problem 3. Electrolyte Imbalances (Hypokalemia)
Problem 4. Hyperglycemia
Problem 5. Systemic Inflammation and Tumor Marker Progression
Problem 6. Cardiovascular Risk
[Findings and Comments]
Recommendations
[Doxaben XL tube feeding]
Doxaben XL (doxazosin) is a sustained-release formulation. Switching to Urief (silodosin) is recommended as an alternative to Doxaben.
[Management of a Patient with Advanced Cancer and Chronic Kidney Disease]
Patient’s Chronic Conditions and Oncological History:
Recent Imaging and Pathology Findings:
Laboratory Results and Recent Issues:
Current Medications and Potential Issues:
Blood Glucose and Insulin Management:
Vital Signs Stability:
Renal Function Monitoring and Adjustments:
Oncology Follow-Up:
Anemia Management:
Lab (not posted)
2024-10-29 CA199 1774.70 U/mL
2024-10-15 CA199 987.42 U/mL
2024-09-26 CA199 650.84 U/mL
2024-07-13 CA199 255.38 U/mL
2024-05-21 CA199 (NM) 133.05 U/mL
2024-10-29 CEA 12.19 ng/mL
2024-10-15 CEA 7.56 ng/mL
2024-09-26 CEA 5.10 ng/mL
2024-07-13 CEA 3.82 ng/mL
2024-05-21 CEA (NM) 2.045 ng/mL
[exam finding]
2024-11-08 HBsAg (NM) Negative
2024-11-08 HBsAg Value (NM) 0.347
2024-11-08 Anti-HCV (NM) Negative
2024-11-08 Anti-HCV Value (NM) 0.033
2024-11-08 Anti-HBs (NM) Positive
2024-11-08 Anti-HBs value (NM) 25.600 mIU/mL
2024-11-08 Anti-HBc (NM) Positive
2024-11-08 Anti-HBc Value (NM) 0.008
2024-11-08 AFP (NM) 3.170 ng/ml
2024-11-08 CEA (NM) 2.400 ng/ml
2024-11-08 CA-153 (NM) 12.200 U/ml
2024-11-08 CA-125 (NM) 29.610 U/ml
2024-02-16 Anti-ENA SS-A (Ro) 1140 EliA U/ml
2024-02-14 Anti-ENA SS-B (La) <0.3 EliA U/ml
2021-11-17 Anti-ENA SS-A (Ro) 385 EliA U/ml
2021-11-16 Anti-ENA SS-B (La) <0.3 EliA U/ml
2020-11-12 Anti-HCV Nonreactive
2020-11-12 Anti-HCV Value 0.07 S/CO
2020-11-12 Anti-HBc Reactive
2020-11-12 Anti-HBc Value 4.53 S/CO
2020-11-12 Anti-HBs 0.00 mIU/mL
2020-11-12 HBsAg Nonreactive
2020-11-12 HBsAg Value 0.48 S/CO
[MedRec]
[chemotherapy]
[Hand-foot syndrome]
Hand-foot syndrome (HFS), also known as palmar-plantar erythrodysesthesia, is a well-documented side effect of certain chemotherapeutic agents, particularly liposomal formulations of doxorubicin (2024-12-06). It manifests as redness, swelling, and pain, primarily on the palms and soles. Autoimmune conditions, like rheumatoid arthritis or systemic autoimmune diseases (2024-11-05), can also contribute to similar symptoms, but their presentation is typically different, involving inflammatory arthritis or vasculitis.
Evidence-based evaluation:
Recommendations:
[Potential HBV Reactivation and Need for Prophylaxis]
Background: The patient has serological evidence of past HBV exposure with the following results:
These findings suggest resolved HBV infection (HBsAg-negative, Anti-HBc-positive, and Anti-HBs-positive). However, her clinical history and immunosuppressive treatments place her at risk for HBV reactivation (HBVr).
Risk Factors for HBVr:
Prophylaxis Recommendation: Prophylactic antiviral therapy is indicated. Options include:
Proposed Plan:
[lab data]
2025-01-14 HBsAg Reactive
2025-01-14 HBsAg Value 1247.57 S/CO
2025-01-14 Anti-HBc Reactive
2025-01-14 Anti-HBc Value 6.86 S/CO
2025-01-14 Anti-HCV Nonreactive
2025-01-14 Anti-HCV Value 0.13 S/CO
[exam finding]
[MedRec]
[surgical operation]
[chemotherapy]
[Patient Summary]
[Problem Comments]
Problem 1. Recurrent Ovarian Cancer with Splenic Metastasis
Problem 2. HBV-Positive Status
Problem 3. General Metabolic and Hematologic Monitoring
[lab data]
2023-08-23 HBsAg Reactive
2023-08-23 HBsAg Value 4279.15 S/CO
2023-08-23 Anti-HBs 0.02 mIU/mL
2023-08-23 Anti-HBc Reactive
2023-08-23 Anti-HBc Value 7.86 S/CO
2023-08-23 Anti-HCV Nonreactive
2023-08-23 Anti-HCV Value 0.10 S/CO
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
2025-01-14 - Opdivo (nivolumab) 240mg NS 100mL 1hr
2024-12-16 - Opdivo (nivolumab) 240mg NS 100mL 1hr
2024-07-15 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (FOLFOX)
2024-06-24 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (FOLFOX)
2024-06-03 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2800mg/m2 4050mg NS 500mL 46hr (FOLFOX)
2024-05-13 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2800mg/m2 4050mg NS 500mL 46hr (FOLFOX)
2024-04-22 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2800mg/m2 4100mg NS 500mL 46hr (FOLFOX)
2024-04-01 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 590mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (FOLFOX)
2024-01-16 - gemcitabine 800mg/m2 1000mg NS 250mL 30min + cisplatin 40mg/m2 30mg NS 500mL 2hr
2024-01-02 - gemcitabine 800mg/m2 1000mg NS 250mL 30min + cisplatin 40mg/m2 30mg NS 500mL 2hr
2023-12-19 - gemcitabine 800mg/m2 1000mg NS 250mL 30min + cisplatin 40mg/m2 30mg NS 500mL 2hr
2023-12-05 - gemcitabine 800mg/m2 1200mg NS 250mL 30min + cisplatin 40mg/m2 57mg NS 500mL 2hr
2023-11-21 - gemcitabine 800mg/m2 1200mg NS 250mL 30min + cisplatin 40mg/m2 57mg NS 500mL 2hr
2023-11-07 - gemcitabine 800mg/m2 1200mg NS 250mL 30min + cisplatin 40mg/m2 57mg NS 500mL 2hr
2023-10-24 - gemcitabine 800mg/m2 1200mg NS 250mL 30min + cisplatin 40mg/m2 57mg NS 500mL 2hr
2023-10-11 - gemcitabine 800mg/m2 1200mg NS 250mL 30min + cisplatin 40mg/m2 57mg NS 500mL 2hr
2023-09-26 - gemcitabine 800mg/m2 1200mg NS 250mL 30min + cisplatin 40mg/m2 57mg NS 500mL 2hr
2023-09-19 - gemcitabine 800mg/m2 1200mg NS 250mL 30min + cisplatin 40mg/m2 57mg NS 500mL 2hr
2023-09-05 - gemcitabine 800mg/m2 1200mg NS 250mL 30min + cisplatin 40mg/m2 57mg NS 500mL 2hr
2023-08-29 - gemcitabine 800mg/m2 1200mg NS 250mL 30min + cisplatin 40mg/m2 57mg NS 500mL 2hr
Systemic therapy for advanced cholangiocarcinoma - 2024-03-05 - https://www.uptodate.com/contents/systemic-therapy-for-advanced-cholangiocarcinoma
[Summary]
This 73-year-old woman with advanced extrahepatic cholangiocarcinoma (post-Whipple operation, 2023-07-26) has metastatic disease involving the lungs and lymph nodes, chronic viral hepatitis B, anemia, and systemic complications. She is currently on nivolumab, an immune checkpoint inhibitor, which introduces additional considerations for her anemia, metastatic disease, and overall care.
[Problems]
Problem 1. Metastatic Extrahepatic Cholangiocarcinoma
Problem 2. Anemia
Problem 3. Chronic Viral Hepatitis B
Problem 4. Reflux Esophagitis and Gastric Issues (hereafter not posted)
Problem 5. Problem: Electrolyte Imbalance (Hyponatremia, Hypokalemia)
The patient, a 73-year-old female with a history of extrahepatic cholangiocarcinoma with pancreatic invasion, is currently undergoing treatment and follow-up for metastatic disease.
Key Summary:
Problem-Oriented Comments:
[lung biopsy planned for extrahepatic bile duct cancer, 2nd line treatment options]
The patient was diagnosed with a malignant neoplasm of the extrahepatic bile duct in the 3rd quarter of 2023 at FuRen University Hospital and subsequently sought chemotherapy treatment at our facility with a regimen of gemcitabine and cisplatin. An attempt to coadminister TS-1 at the beginning of treatment was made but was quickly discontinued due to the patient’s intolerance.
The final dose of the gemcitabine and cisplatin regimen was administered on 2024-01-16, marking nearly six months of treatment, followed by a CT scan on 2024-02-20 that suggested potential disease progression. Currently, the patient is being prepared for a lung biopsy to investigate suspected metastasis.
The patient’s underlying hypertension is now being managed with Concor (bisoprolol) and Exforge (amlodipine, valsartan), aligning with the repeat prescriptions recorded in the PharmaCloud database. The patient’s vital signs and lab results (2024-03-04) were grossly within normal limits, with no discrepancies in medication identified.
Should disease progression be confirmed, several candidate regimens for second-line therapy could be contemplated, encompassing: FOLFOX; liposomal irinotecan; capecitabine combined with oxaliplatin; capecitabine paired with irinotecan; fluoropyrimidine as a standalone treatment; and antiangiogenic therapies, which include bevacizumab, regorafenib, and ramucirumab.
Molecularly targeted therapy represents an alternative approach when next-generation sequencing is employed to identify actionable molecular abnormalities.
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
[Betmiga (mirabegron) - tube feeding]
Betmiga (mirabegron) is a long-acting formulation and is not recommended to be crushed or split for tube feeding. Since the effect of mirabegron 50 mg is approximately equivalent to propiverine 30 mg, switching to Urotrol (propiverine 15 mg) at a dosage of 1 tablet twice daily (BID) is advised for tube feeding.
[Summary]
The patient is a 66-year-old male with advanced intrahepatic cholangiocarcinoma (T4N1M1, Stage IV) undergoing combination chemotherapy (gemcitabine/cisplatin) and immunotherapy (durvalumab). His clinical course is complicated by:
[Problems]
Anemia (HGB 9.0 g/dL on 2024-12-30)
Persistent Inflammatory State
Track inflammatory markers (e.g., CRP, procalcitonin) and WBC count. - Repeat blood cultures to confirm clearance of bacteremia. - Chest imaging (e.g., CT) to assess for structural lung pathology or abscess.
Electrolyte and Nutritional Imbalances
[anemia]
The patient presents with anemia, evident from consistent findings of low hemoglobin (HGB) levels across multiple dates.
Classification of Anemia
Temporal Evidence
Contributing Factors and Etiologies
Suggested Next Steps
[exam findings] (not completed)
[MedRec] (not completed)
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
G-CSF
There were no medication reconciliation issues when reviewing PharmaCloud and HIS5 records.
[Leukemia has been managed more effectively]
Leukopenia has become less severe and less frequent following the intermittent administration of prophylactic/therapeutic Granocyte (lenograstim) in accordance with chemotherapy cycles. This approach has improved the management of this side effect.
[reconciliation]
Currently, the patient’s medication records are not accessible on PharmaCloud. However, after reviewing the HIS5 records, no medication reconciliation issues were found.
[leukopenia]
At this time, the patient is not experiencing severe leukopenia. Any leukopenia events that have occurred since the start of the [bevacizumab paclitaxel cisplatin] regimen on 2023-05-26 have been treated with G-CSF administrations without reducing the dose of paclitaxel or cisplatin.
Based on the PharmaCloud database, this patient has exclusively attended our hospital for outpatient and inpatient services across the departments of urology, obstetrics and gynecology, radiation-oncology, and hemato-oncology in the past three months. No issues were found during medication reconciliation.
[reconciliation]
[more intensive hydration]
[leukopenia]
This patient last received paclitaxel and cisplatin on 2023-05-15 and a WBC nadir of 1.16K/uL was noted on 2023-05-25. Paclitaxel carries a Boxed Warning regarding bone marrow suppression and recommends frequent peripheral blood cell counts for all patients receiving the drug. Granocyte (lenograstim 250ug) was administered for three consecutive days starting on 2023-05-25.
According to the reimbursement guidelines of the Taiwan National Health Insurance, the use of G-CSF is allowed for patients with non-hematologic malignancies who have a WBC count of less than 1000/uL or an absolute neutrophil count (ANC) of less than 500/uL after chemotherapy. This patient meets the specified criteria (neutrophil 14.7%), so G-CSF can be prescribed to manage leukopenia following this round of chemotherapy.
[exam findings]
[MedRec]
[immunochemotherapy]
2025-01-10 - pembrolizumab 200mg NS 100mL 30min (Keytruda self-paid)
2024-12-11 - pembrolizumab 200mg NS 100mL 30min (Keytruda self-paid)
2024-11-19 - pembrolizumab 200mg NS 100mL 30min + paclitaxel 175mg/m2 330mg NS 500mL 3hr + carboplatin AUC 5 600mg NS 250mL 30min (Keytruda self-paid)
2024-10-24 - pembrolizumab 200mg NS 100mL 30min + paclitaxel 175mg/m2 330mg NS 500mL 3hr + carboplatin AUC 5 600mg NS 250mL 30min (Keytruda self-paid)
2024-09-17 - pembrolizumab 200mg NS 100mL 30min + paclitaxel 175mg/m2 330mg NS 500mL 3hr + carboplatin AUC 5 600mg NS 250mL 30min (Keytruda self-paid)
2024-08-23 - pembrolizumab 200mg NS 100mL 30min + paclitaxel 175mg/m2 330mg NS 1000mL 3hr + carboplatin AUC 5 600mg NS 250mL 30min (Keytruda self-paid)
2024-08-01 - pembrolizumab 200mg NS 100mL 30min + paclitaxel 175mg/m2 330mg NS 1000mL 3hr + carboplatin AUC 5 600mg NS 250mL 30min (Keytruda self-paid)
2024-07-09 - pembrolizumab 200mg NS 100mL 30min + paclitaxel 175mg/m2 330mg NS 1000mL 3hr + carboplatin AUC 5 600mg NS 250mL 30min (Keytruda self-paid)
2024-06-12 - pembrolizumab 200mg NS 100mL 30min + paclitaxel 175mg/m2 330mg NS 1000mL 3hr + carboplatin AUC 5 600mg NS 250mL 30min (Keytruda self-paid)
2024-05-20 - pembrolizumab 200mg NS 100mL 30min + paclitaxel 175mg/m2 340mg NS 1000mL 3hr + carboplatin AUC 5 600mg NS 250mL 30min (Keytruda self-paid)
[Patient Summary]
The patient is a 47-year-old postmenopausal woman with a history of endometrial adenocarcinoma with lymph node metastases (pT3aN1M0, FIGO pStage IIIC1) diagnosed in 2014 and treated with surgery and chemotherapy.
She developed recurrent bilateral lung metastases in 2017 and is currently receiving immunotherapy with Keytruda (pembrolizumab) along with a regimen of paclitaxel and carboplatin, followed by maintenance therapy with Keytruda (pembrolizumab). The disease appears stable on imaging (2024-11-20 CT, 2024-05-21 bone scan) without significant new progression.
Management also involves chronic viral hepatitis B and symptom control for treatment-related side effects.
[Problem Comments]
Problem 1: Lung Metastases
Problem 2: Chronic Viral Hepatitis B
Problem 3: Fatty Liver
Problem 4: Potential Bone Metastases
Problem 5: Anemia
Hypokalemia was noted on 2024-07-08. Oral potassium supplementation (Const-K) is currently used, no medication problems found.
[exam finding]
[MedRec]
[consultation]
[Medication]
[Fosamax Plus - tube feeding]
The FOSAMAX PLUS (alendronate 70mg, colecalciferol 140 ug 5600 IU) package insert states: “Similar to other formulations containing bisphosphonates, FOSAMAX PLUS may cause localized irritation to the upper gastrointestinal mucosa. The risk of severe esophageal adverse reactions is heightened if patients lie down after taking FOSAMAX PLUS, fail to accompany the medication with a full glass of plain water, or continue its use despite experiencing esophageal irritation.”
Administration of the medication via tube feeding, bypassing the esophagus, should theoretically not result in esophageal mucosal irritation.
[Problem Comments]
Problem 1: Sepsis with Multi-Organ Dysfunction
Problem 2: Acute Kidney Injury (AKI) on Chronic Kidney Disease (CKD)
Problem 3: Liver Dysfunction and Hepatic Encephalopathy
Problem 4: Pleural Effusions and Respiratory Dysfunction
Summary of Key Actions (not posted)
[Problem Comments]
Problem 1: Infection and Suspected Sepsis
Problem 2: Hyperglycemia and Suboptimal Glycemic Control
Problem 3: Hypercoagulable State
Problem 4: Electrolyte Imbalance (Hyperkalemia)
[Hypercoagulability and Risk of Thrombosis] (not posted)
Assess Coagulation Status
Manage Hypercoagulability and Risk of Thrombosis
Address the Systemic Infection
Glycemic Control
Address Electrolyte Imbalances
Monitor and Manage Oncological Issues
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
2025-01-09 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
2024-12-11 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
2024-11-18 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
2024-09-09 - (debulking surgery)
2024-07-31 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
2024-07-06 - paclitaxel 175mg/m2 265mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
2024-06-17 - paclitaxel 175mg/m2 265mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
[successful reduction of ca125 with paclitaxel and carboplatin]
The tumor marker CA125 readings have continued to decrease after initiating the paclitaxel and carboplatin regimen on 2024-06-17. Lab data on 2024-07-30 were generally acceptable. No medication discrepancies were identified.
[exam finding]
[MedRec]
[consultation]
[immunochemotherapy]
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
[Patient Summary]
This is a 77-year-old patient diagnosed with ductal adenocarcinoma of the pancreatic tail, pT2N0M1, Stage IV, with progression of metastatic pleural disease. The primary tumor has remained stable, but pleural effusion and pleural seeding have worsened. The patient is undergoing systemic chemotherapy, with gemcitabine, nab-paclitaxel, and cisplatin added later, potentially reflecting attempts to address platinum-sensitive disease (e.g., suspected BRCA1/2 or PALB2 mutation sensitivity).
[Problem Comments]
Problem 1: Metastatic Pleural Effusion with Pleural Seeding
Problem 2: Primary Pancreatic Tail Tumor
Problem 3: Systemic Disease Burden and Treatment Tolerance
[exam finding]
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
[Patient Summary]
The patient is a 40-year-old male diagnosed with non-small cell lung carcinoma (NSCLC), favoring adenocarcinoma, with multiple bone metastases, including the cervical spine, thoracic spine, and left femur, among others. The disease is staged as cT4N3M1c, Stage IV, with extensive bony destruction and systemic metastases evidenced by imaging and laboratory findings (2024-12-07 CT, 2024-12-13 PET, 2024-12-12 bone scan).
He is undergoing systemic therapy with Cisplatin/Paclitaxel and radiation therapy for both the primary tumor and metastatic lesions (2024-12-18 chemotherapy initiation, 2024-12-13 XRT initiation). The patient also experiences paraneoplastic symptoms, including hypercalcemia, which was initially treated successfully (2024-12-05 lab corrected calcium 3.26 mmol/L).
Despite treatment, the disease continues to progress with lower limb paralysis secondary to spinal cord compression by metastatic lesions (2024-12-23 MRI findings). He is currently on a multimodal palliative treatment plan that includes pain control, radiotherapy, and systemic chemotherapy.
[Problem Comments]
Problem 1: Non-Small Cell Lung Carcinoma (NSCLC) with Bone Metastases
Problem 2: Spinal Cord Compression
Problem 3: Hypercalcemia
Problem 4: Pain Management
[exam finding]
[consultation]
[chemotherapy]
[Patient Summary]
This 60-year-old male patient presents with advanced transverse colon adenocarcinoma (diagnosed via biopsy on 2024-12-24), complicated by peritoneal carcinomatosis, liver and lung metastases, and multiple lymph node metastases (imaging evidence: MRI 2024-12-25 and CT 2024-12-17). The patient also has a history of chronic hepatitis B (diagnosed 30 years ago). Current concerns include refractory hypotonic hyponatremia with hypervolemia, anemia, and significant weight loss (10 kg over 3 months). Initial chemotherapy with modified FOLFIRI + Avastin (irinotecan 20% off) started on 2025-01-05.
[Problem Comments]
Problem #1: Advanced Transverse Colon Adenocarcinoma with Metastases
Problem #2: Refractory Hypotonic Hyponatremia with Hypervolemia
Problem #3: Anemia
Problem #4: Chronic Hepatitis B
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
[Patient Summary]
This is a 68-year-old male patient with a history of lung squamous cell carcinoma (pT2aN1M0, stage IIB), chronic obstructive pulmonary disease (COPD), chronic systolic heart failure, ischemic heart disease, and coronary artery disease (CAD) status post percutaneous coronary intervention (PCI) with a drug-eluting stent in the right coronary artery and a drug-coated balloon in the left anterior descending artery (2024-05-16). Following a right lower lobe lobectomy and lymph node dissection on 2024-11-20, the patient is planned for adjuvant chemotherapy (weekly docetaxel and cisplatin) with consideration for concurrent chemoradiotherapy (CCRT) due to suspected close surgical margins (2025-01-03). Pre-chemotherapy considerations include renal function monitoring (creatinine clearance and 24-hour CCr on 2025-01-04) and management of underlying conditions.
[Problem Comments]
[exam finding]
[MedRec]
[surgical operation]
[chemotherapy]
[Patient Summary]
The patient, a 58-year-old woman, has been diagnosed with invasive lobular carcinoma (2024-07-31 pathology) of the right breast (ER+, PR+, HER2-, Ki-67 5%) with a history of partial mastectomy and axillary lymph node dissection. Post-surgery, the patient underwent adjuvant chemotherapy with Doxorubicin + Cyclophosphamide (2024-08-22 to 2024-11-04) and transitioned to Docetaxel-based chemotherapy (2024-11-25 to 2025-01-06). Complications include neutropenia (grade II, 2024-12-19) and metabolic imbalances (hypomagnesemia, hypocalcemia, 2024-12-19). The patient also has a history of chronic hepatitis B managed with Vemlidy (tenofovir alafenamide).
Laboratory findings reveal hyperglycemia with blood glucose ranging from 214 to 287 mg/dL on 2025-01-05 to 2025-01-06, which could indicate steroid-induced diabetes or poor glucose control. Vital signs are stable with no acute abnormalities in blood pressure or SpO2 (2025-01-05 to 2025-01-06).
[Problem Comments]
Problem 1. Breast Cancer Management
Problem 2. Metabolic Imbalances (Hyperglycemia, Hypomagnesemia, Hypocalcemia)
Problem 3. Chronic Hepatitis B
Problem 4. Neutropenia (Grade II)
[Treatment Assessment]
Based on the patient data from HIS5 and the referenced NCCN guidelines (2024-10-15)
Start an aromatase inhibitor (AI) (e.g., Letrozole, Anastrozole, or Exemestane) following the completion of chemotherapy (Docetaxel, 2025-01-06).
Consider adjuvant bisphosphonate therapy (e.g., zoledronic acid) to counteract AI-induced bone loss, as she is at risk of osteoporosis.
Proposed Plan
[exam finding]
2024-12-07 11:25 ECG
2024-12-05 Patho - gallbladder (benign lesion)
2024-12-05 Patho - liver partial resection
2024-11-21 Flow Volume Chart
2024-11-21 2D transthoracic echocardiography
2024-11-19 Percutaneous Transhepatic GallBladder Drainage, PTGBD
2024-11-18 Patho - pancreas biopsy
2024-11-18 Endoscopic ultrasound, EUS
2024-11-18 SONO - abdomen
2024-11-14 MRI
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
[Patient Summary]
This 73-year-old male patient with pancreatic head adenocarcinoma (moderately differentiated), complicated by liver metastases (evidenced by imaging and pathology on 2024-12-05), has undergone significant surgical and medical management. He has a history of obstructive jaundice (2024-11-14), Type 2 diabetes mellitus (DM), hypertension, and asthma. Recent treatments include a Roux-en-Y gastrojejunostomy, hepaticojejunostomy, open cholecystectomy, and liver partial resection (2024-12-05). Currently, he is undergoing chemotherapy with Gemzar (gemcitabine) and Abraxane (nab-paclitaxel) initiated on 2025-01-03.
He presents with anemia, persistent elevated liver enzymes, fluctuating bilirubin levels, controlled glycemic levels, and an ECOG performance status of 1 post-surgery.
[Problem Comments]
Problem 1. Pancreatic Head Adenocarcinoma with Liver Metastasis (Stage IV)
Problem 2. Anemia
Problem 3. Diabetes Mellitus (DM)
Problem 4. Nutritional Deficiencies
Probelm 5. Biliary and Liver Function
Problem 6. Pulmonary Function
Problem 7. Pain Management
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
2023-10-31 ~ 2023-11-13 - completed RT to spine T10-L1: 30 Gy/ 10 fx.
2023-03-16 ~ 2023-04-28 - completed RT to the rectal tumor and regional LNs: 45 Gy/ 25 fx. The rectal tumor (with the invaded uterus) and LAPs: 54 Gy/ 30 fx.
[chemotherapy]
2024-12-18 - cetuximab 500mg/m2 400mg 2hr + oxaliplatin 65mg/m2 95mg D5W 250mL 2hr + leucovorin 300mg/m2 430mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 48hr (infusor) (Erbitux + FOLFOX. Erbitux only 4 vials left)
2024-12-03 - cetuximab 500mg/m2 600mg 2hr + oxaliplatin 65mg/m2 95mg D5W 250mL 2hr + leucovorin 300mg/m2 430mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 48hr (infusor) (Erbitux + FOLFOX)
2024-11-07 - leucovorin 20mg/m2 30mg NS 250mL 10min + fluorouracil 425mg/m2 630mg NS 250mL 10min (5-FU for CCRT)
2024-10-04 - cetuximab 500mg/m2 700mg 2hr + oxaliplatin 65mg/m2 90mg D5W 250mL 2hr + leucovorin 300mg/m2 440mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Erbitux + FOLFOX)
2024-09-09 - cetuximab 500mg/m2 700mg 2hr + oxaliplatin 65mg/m2 90mg D5W 250mL 2hr + leucovorin 300mg/m2 440mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Erbitux + FOLFOX)
2024-08-24 - cetuximab 500mg/m2 700mg 2hr + irinotecan 120mg/m2 170mg D5W 250mL 90min + leucovorin 300mg/m2 430mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Erbitux + FOLFIRI)
2024-07-31 - cetuximab 500mg/m2 700mg 2hr + irinotecan 120mg/m2 170mg D5W 250mL 90min + leucovorin 300mg/m2 430mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Erbitux + FOLFIRI)
2024-07-08 - bevacizumab 5mg/kg 200mg NS 100mL 1.5hr + irinotecan 120mg/m2 170mg D5W 250mL 90min + leucovorin 300mg/m2 430mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI)
2024-06-17 - ……………………………………. leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr
2024-05-28 - irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI)
2024-05-09 - irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI)
2024-04-17 - irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI)
2024-03-22 - irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI)
2024-01-18 - bevacizumab 5mg/kg 300mg NS 100mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr
2023-12-29 - bevacizumab 5mg/kg 300mg NS 100mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr
2023-12-08 - bevacizumab 5mg/kg 300mg NS 100mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr
2023-11-09 - bevacizumab 5mg/kg 300mg NS 100mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr
2023-09-27 - bevacizumab 5mg/kg 300mg NS 100mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr
2023-09-08 - bevacizumab 5mg/kg 300mg NS 100mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr
2023-08-17 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (A-FOLFIRI; Q2W)
2023-08-01 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (A-FOLFIRI; Q2W)
2023-07-12 - ………………………………….. irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (A-FOLFIRI; Q2W)
2023-06-26 - ………………………………….. oxaliplatin 65mg/m2 90mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX, Q2W)
2023-05-29 - bevacizumab 5mg/kg 300mg NS 200mL 90min + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 400mg/m2 580mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFOX, Q2W)
2023-04-28 - ………………………………….. oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 400mg/m2 580mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX, Q2W)
2023-04-11 - ………………………………….. oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 400mg/m2 580mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX, Q2W)
2023-03-23 - ………………………………….. oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 400mg/m2 650mg NS 250mL 10min + fluorouracil 2400mg/m2 3900mg NS 500mL 46hr (FOLFOX, Q2W)
[Key Summary]
The patient is a case of a critically ill individual with advanced metastatic rectal cancer (cT4aN2bM1a, stage IVA), significant liver and lung metastases, portal hypertension, ascites, thrombosis of the left portal vein, and secondary complications including renal dysfunction, infection, anemia, and malnutrition.
Current findings suggest systemic inflammation/infection (elevated procalcitonin: 8.06 ng/mL on 2025-01-01), acute kidney injury (creatinine: 2.27 mg/dL on 2025-01-01, eGFR: 23.11 mL/min/1.73 m²), progressive anemia, and coagulopathy. The patient is receiving critical support, including intravenous (IV) albumin, vasopressors, and antibiotics.
[Problem Comments]
Problem 1. Sepsis/Systemic Inflammation
Problem 2. Acute Kidney Injury (AKI)
Problem 3. Anemia and Coagulopathy
Problem 4. Hyperbilirubinemia and Malnutrition
[monitoring upward trend in CEA and CA199, addressing liver cirrhosis and metastasis, potential sodium supplementation for hyponatremia]
Lab results on 2024-05-27 showed hyponatremia (130 mmol/L), hypomagnesemia (1.7 mg/dL), hyperalbuminemia (3.3 g/dL), and hyperbilirubinemia (total 1.22 mg/dL, direct 0.40 mg/dL). The latter two are likely related to liver cirrhosis and metastases. Currently, MgSO4 and BaoGan are in use. The addition of sodium supplementation might be further considered.
The CT imaging conducted on 2024-03-25 showed that the rectal cancer with liver metastases remained stationary. However, the updated markers CEA and CA199 seem to be trending upward and should be closely monitored.
2024-05-15 CEA 52.67 ng/mL
2024-04-25 CEA 41.73 ng/mL
2024-04-01 CEA 26.22 ng/mL
2024-03-12 CEA (NM) 18.827 ng/mL
2024-02-02 CEA (NM) 9.794 ng/mL
2024-01-18 CEA 15.20 ng/mL
2024-01-16 CEA (NM) 4.550 ng/mL
2024-05-15 CA199 46.60 U/mL
2024-04-25 CA199 36.37 U/mL
2024-04-01 CA199 27.00 U/mL
2024-03-12 CA199 (NM) 52.022 U/mL
2024-02-02 CA199 (NM) 37.571 U/mL
2024-01-18 CA199 27.25 U/mL
2024-01-16 CA199 (NM) 34.438 U/mL
[thrombocytopenia]
Thrombocytopenia was first observed in April 2023 and has not yet returned to the lower limit of normal range (150K/uL). Since December, platelet counts have been consistently below 50K/uL. Bevacizumab was started in August 2023.
Both bevacizumab and fluorouracil are known to cause thrombocytopenia, with bevacizumab showing a higher incidence rate of up to 58% (grades 3/4: 20% to 40%).
According to UpToDate recommendations, in cases of hemorrhage caused by bevacizumab, such as hemoptysis (recent history of >= 2.5 mL), bevacizumab should be withheld. For Grade 3 or 4 hemorrhage, bevacizumab should be discontinued. As there has been no recent documentation of hemorrhage found in the medical records, it may not be necessary to temporarily stop the use of bevacizumab at this time.
Blood transfusion has been scheduled according to the progress note.
The patient has only visit our hospital in the last 3 months according to the PharmaCloud database, our gastroenterologist prescribed Baraclude (entecavir) for she is a carrier of viral hepatitis B. Baraclude is in the active medication list, no reconciliation issues found.
On 2023-06-18, the patient’s fecal occult blood test was 2+, indicating a possible GI bleeding. On this date, the patient has been prescribed lansoprazole and tranexamic acid. The prescription for lansoprazole is set to expire on 2023-06-21. It would be beneficial to evaluate whether signs of bleeding persist to decide whether to continue the PPI.
[exam finding]
[MedRec]
2024-12-31 ~ 2025-01-01 POMR General and Gastroenterological Surgery Zhang YaoRen
2024-11-01 ~ 2024-11-02 POMR General and Gastroenterological Surgery Zhang YaoRen
2024-09-16 Radiation Oncology Chang YouKang
2024-09-13 ~ 2024-09-14 POMR General and Gastroenterological Surgery Zhang JianHui
2024-09-10 Radiation Oncology Chang YouKang
2024-09-05 SOAP Gastroenterology Li ZhongXian
2024-08-26 SOAP General and Gastroenterological Surgery Zhang YaoRen
2024-08-06 SOAP Radiation Oncology Chang YouKang
2024-08-05 SOAP General and Gastroenterological Surgery Zhang YaoRen
2024-07-15 SOAP General and Gastroenterological Surgery Zhang YaoRen
2024-06-24 SOAP General and Gastroenterological Surgery Zhang YaoRen
2024-06-13 SOAP Gastroenterology Li ZhongXian
2024-06-12 SOAP General and Gastroenterological Surgery Zhang YaoRen
2024-06-03 SOAP General and Gastroenterological Surgery Zhang YaoRen
2024-05-10 ~ 2024-05-11 POMR General and Gastroenterological Surgery Zhang YaoRen
2024-04-18 ~ 2024-04-19 POMR General and Gastroenterological Surgery Zhang YaoRen
2024-03-27 ~ 2024-03-28 POMR General and Gastroenterological Surgery Zhang YaoRen
2024-02-21, -02-07 SOAP General and Gastroenterological Surgery Zhang YaoRen
2023-11-22, -08-30, -06-07 SOAP General and Gastroenterological Surgery Zhang YaoRen
2023-03-15, 2022-12-21, -09-28, -06-30 SOAP General and Gastroenterological Surgery Zhang YaoRen, Zhang JianHui
2022-06-06 SOAP General and Gastroenterological Surgery Zhang JianHui
[chemotherapy]
[Treatment Effectiveness and Hematologic Adverse Effects of Ribociclib]
The patient has a history of invasive carcinoma of no special type (NST) initially diagnosed via a breast biopsy on 2022-05-17, followed by a right simple mastectomy on 2022-06-27, confirming Grade 1 invasive carcinoma and ductal carcinoma in situ (DCIS) with negative resection margins and no lymphovascular or perineural invasion. AJCC 8th edition stage was determined as pT1cN0, anatomic stage IA, indicating early-stage disease. Hormonal receptor positivity (ER 100%, PR 1%) and HER2 negativity (score 1+) suggest a luminal A-like phenotype (2024-02-16).
Following surgery, the patient underwent adjuvant hormone therapy with Femara (letrozole), maintained regularly from 2022-06-06 until 2024Q4. Progressive lymph node involvement was noted in 2024-02-27 with metastatic invasive carcinoma identified in 2/4 right axillary lymph nodes. This prompted systemic chemotherapy with cyclophosphamide and liposomal doxorubicin (AC(lipo)) initiated on 2024-03-06, followed by docetaxel cycles from 2024-06-03 to 2024-08-05.
Ribociclib (Kisqali) was introduced on 2024-09-13 as part of a combination regimen for metastatic disease control alongside ongoing letrozole. Imaging on 2024-09-06 indicated reduced glucose hypermetabolic activity in previously noted areas, including the mediastinal LAPs and right axillary region, suggesting treatment effectiveness. No evidence of distant metastatic disease was noted on follow-ups (2024-09-13 MRI brain, 2024-11-25 abdominal ultrasound).
[Comments on Neutropenia]
[Addressing Hematologic Adverse Effects of Ribociclib]
Lab data
2024-11-01 WBC 1.37 x10^3/uL
2024-10-07 WBC 1.17 x10^3/uL
2024-09-23 WBC 2.94 x10^3/uL
2024-09-13 WBC 5.81 x10^3/uL
2024-08-05 WBC 5.46 x10^3/uL
2024-07-15 WBC 5.55 x10^3/uL
2024-06-24 WBC 5.93 x10^3/uL
2024-06-12 WBC 1.03 x10^3/uL
2024-06-03 WBC 2.19 x10^3/uL
2024-05-10 WBC 2.87 x10^3/uL
2024-04-18 WBC 3.34 x10^3/uL
2024-03-27 WBC 2.72 x10^3/uL
2024-03-13 WBC 5.30 x10^3/uL
2024-02-26 WBC 4.34 x10^3/uL
2024-11-01 Neutrophil 74.3 %
2024-10-07 Neutrophil 58.6 %
2024-09-23 Neutrophil 74.5 %
2024-09-13 Neutrophil 57.1 %
2024-08-05 Neutrophil 56.9 %
2024-07-15 Neutrophil 84.5 %
2024-06-24 Neutrophil 71.6 %
2024-06-12 Neutrophil 26.8 %
2024-06-03 Neutrophil 51.6 %
2024-05-10 Neutrophil 65.9 %
2024-04-18 Neutrophil 63.4 %
2024-03-27 Neutrophil 59.9 %
2024-03-13 Neutrophil 66.6 %
2024-02-26 Neutrophil 65.6 %
Case Context
Recommendations
This patient’s neutropenia appears treatment-related and is manageable with dose adjustments, potential G-CSF support, and close monitoring. Balancing effective cancer therapy with minimizing adverse effects is crucial in older, comorbid patients, as emphasized by the NCCN guidelines. The suggested adjustments aim to maintain efficacy while reducing the risk of severe hematologic complications.
[exam finding]
[surgical operation]
[Patient Summary]
This is a 43-year-old male with a history of hypertension under medical control and a prior excision of a thigh mass (2024-04-02, lipomatous and panniculitis change), presenting with intractable back pain and bilateral lower limb weakness and numbness over the past two weeks. MRI of the thoracic spine (2024-12-22) revealed abnormal marrow changes in the T10 and T11 vertebrae with an epidural tumor invasion, highly suspicious for metastatic lesions. Pathological confirmation (2024-12-25) identified the lesion as diffuse large B-cell lymphoma (DLBCL), GCB subtype.
Additionally, he underwent T10-11 laminectomy and T11 kypho-vertebroplasty (2024-12-24) with findings of significant spinal cord compression by an epidural tumor. Neurological deficits and mechanical back pain remain significant clinical issues. Laboratory findings, imaging, and histopathology collectively suggest a systemic lymphoma involving the spine, with no prior documented malignancy history.
[Problem Comments]
Problem #1: T11 Pathologic Fracture with Epidural Spinal Cord Compression
Problem #2: L-Spine Degenerative Changes and Mechanical Instability
Problem #3: Systemic Evaluation and Tumor Staging
Final Plan Summary:
[lab data]
2024-11-21 HLA A-high 02:06
2024-11-21 HLA A-high 02:07
2024-11-21 HLA B-high 46:01
2024-11-21 HLA B-high 55:02
2024-11-21 HLA C-high 01:02
2024-11-21 HLA C-high 03:03
2024-11-21 HLA DQ-high 03:03
2024-11-21 HLA DQ-high -
2024-11-21 HLA DR-high 09:01
2024-11-21 HLA DR-high -
2024-10-16 JAK2 gene mutation quan 0.00 %
2024-10-16 FLT3-D835 (BM) Undetectable
2024-10-16 P.jiroveci DNA-Sp Undetectable
2024-10-09 FLT3/ITD (BM) Presence of mutation
2024-10-09 NPM1 (qual) (BM) Undetectable
2024-10-04 HBsAg Reactive
2024-10-04 HBsAg Value 4628.62 S/CO
2024-10-04 Anti-HBc Reactive
2024-10-04 Anti-HBc Value 9.07 S/CO
2024-10-04 Anti-HCV Nonreactive
2024-10-04 Anti-HCV Value 0.21 S/CO
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
Acute Myeloid Leukemia (AML) with FLT3/ITD Mutation
Infection-Related Complications
Defer live vaccines until the patient has completed chemotherapy and demonstrated immune recovery (WBC ≥3.0 × 10³/μL, ANC ≥1.5 × 10³/μL).
Pneumococcal vaccines can be scheduled during immune recovery phases or after chemotherapy, as they are critical for preventing severe pneumococcal disease in this high-risk patient.
Hematologic Findings and Supportive Care
Cardiopulmonary Concerns
Chronic Conditions: COPD
Nutrition and Metabolic Status
[exam findings]
[MedRec]
[Surgical operation]
[chemotherapy]
GRAALL-2003 regimen - 2024-12-26 - Perplexity
The GRAALL-2003 regimen is a pediatric-inspired treatment protocol for adults with Philadelphia chromosome-negative acute lymphoblastic leukemia (ALL). This regimen was designed for patients aged 15 to 60 years and showed improved outcomes compared to previous adult ALL protocols3.
Induction
Consolidation - Consists of 9 alternating blocks:
Late Intensification - Administered between consolidation blocks 6 and 7, with different regimens for patients in complete remission (CR) after first induction or salvage course1.
Maintenance Therapy
CNS Prophylaxis
Citations:
This 18-year-old male patient has T-cell acute lymphoblastic leukemia (T-ALL) initially diagnosed on 2024-04-22. He is undergoing treatment per the GRAALL-2003 regimen, currently in Block 9 of consolidation chemotherapy. Historical bone marrow examinations indicate periods of remission (2024-06-07, 2024-09-01) followed by residual disease recurrence (2024-11-11). His current hospitalization included chemotherapy from 2024-12-24 to 2024-12-25, and a bone marrow evaluation is pending as of 2024-12-26. His clinical condition is stable, and he will be discharged on Lenograstim for home management, with outpatient follow-up arranged.
Problem 1: Acute Lymphoblastic Leukemia (T-ALL) with Residual Disease
Problem 2: Risk of Treatment-Related Toxicities
Problem 3: Long-Term Management of T-ALL
[Neutropenia: Determining Cause and Treatment Options]
The patient has developed neutropenia recently. While the Oncoginase package insert doesn’t emphasize neutropenia as an important side effect, the medications administered on 2024-05-20 - daunorubicin, vincristine, and cyclophosphamide - are known to be more likey to cause neutropenia.
If a further decrease in WBC count is anticipated, the use of G-CSF could be considered as a proper measure.
[Key Summary]
Primary Concerns: The patient, a 66-year-old male, presents with normocytic anemia, generalized lymphadenopathy, and a suspected lymphoma (evidence: MRI pelvis on 2020-11-06, CT abdomen/pelvis on 2024-11-14).
Comorbidities: Coronary artery disease, severe aortic stenosis, chronic kidney disease (stage III), paroxysmal atrial fibrillation, type 2 diabetes mellitus with diabetic nephropathy, and old cerebrovascular accident with left hemiplegia.
Notable Labs:
Physical Exam: A 3 cm nodule in the left neck, hyperpigmented skin, and generalized lymphadenopathy.
Medications: Includes antihypertensives, antiplatelets, anticoagulants, and diabetic medications.
[Problem-Oriented Comments]
Problem 1: Normocytic Anemia
Problem 2: Generalized Lymphadenopathy
Problem 3: Chronic Kidney Disease (Stage III)
[Medication Review]
[exam finding]
[MedRec]
[radiotherapy]
[chemotherapy]
[Key Summary]
The patient is a 72-year-old male with stage IIIa adenocarcinoma of the sigmoid colon (cTxN1M0), undergoing Total Neoadjuvant Therapy (TNT) with concurrent chemoradiation (CCRT) and FOLFOX. He was admitted with febrile neutropenia and hypokalemia. Abdominal imaging reveals significant gastrointestinal findings, including ileus and bowel wall edema. Laboratory data confirms neutropenia with an absolute neutrophil count (ANC) of 172 (2024-12-25) and hypokalemia (K+ 2.8 mmol/L).
[Problem-Oriented Comments]
Problem 1: Neutropenia with Fever
Problem 2: Hypokalemia
Problem 3: Bowel Symptoms (Diarrhea and Ileus)
[Medication Review]
[exam finding] (not completed)
[MedRec]
[immunochemotherapy]
{Prostate cancer, pT3bN1cM0, s/p RARP on 2015-06-30, s/p adjuvant radiotherapy on 2015-09-25 and hormone therapy with refractory, progression of metastatic paraaortic lymph nodes and bone metastases, T0N0M1a, stage IV}
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
certain medication
[stable PSA levels under docetaxel and goserelin regimen, prophylactic G-CSF proves effective in preventing neutropenia, considering denosumab reintroduction for spine metastasis findings]
Under the current docetaxel and goserelin regimen, the patient’s PSA levels have remained stable at around 70 ng/mL, consistent with the past few months, indicating the disease is still under control.
Since 2021-11, Granocyte (lenograstim) has been administered for three consecutive days, starting approximately one week after almost each docetaxel treatment. Recent data shows very few instances of neutropenia, suggesting the prophylactic use of G-CSF has been effective.
Apart from anemia, lab results are generally normal, and no medication issues have been identified.
Xgeva (denosumab) was used between 2022-08 and 2023-10, but a follow-up MRI on 2024-07-06 showed retrolisthesis of L2 on L3 (grade I), multiple ill-defined mass lesions over the lumbar and sacral spine consistent with metastases, and spondylolisthesis of L4 on L5 (grade I). Given these findings, it is recommended to evaluate whether to resume Xgeva based on the patient’s overall clinical condition.
[stable PSA and disease control with ongoing disease control with docetaxel and goserelin]
PSA levels have remained stable at around 70 ng/mL over the past three months. A July CT scan, compared with the previous quarter, indicates that the disease has remained stable, suggesting that the current docetaxel and goserelin regimen is still effective.
Other lab results from 2024-08-19 were generally normal, and no medication discrepancies were identified.
[stable PSA levels post-docetaxel therapy; managing HBV reactivation and neutropenia effectively]
Since initiating docetaxel treatment on 2023-09-28 after a six-month interval, there appears to be no trend of PSA doubling as of late December 2023, suggesting a stable response to the therapy.
Lab tests on 2024-04-10 were largely normal. The patient continues to take Baraclude (entecavir) and Granocyte (lenograstim) is used as a preventive measure against HBV reactivation and neutropenia, similar to previous protocols, with no discrepancies in medication identified.
2023-01-04 lab data were generally normal, except for a slight decrease in WBC and HGB levels. The vital signs of the patient are stable during this hospitalization.
All underlying conditions, including HBV, hypothyroidism, and insomnia, are managed with appropriate medication.
assessment
suggestion
assessment
suggestion
[exam finding] (not completed)
2024-12-16 CT - abdomen
2024-11-11 Ascites tapping
2024-11-05 PTCD (percutaneous transhepatic cholangial drainage) revision
2023-11-01 Patho - liver biopsy needle/wedge
2024-10-30 ECG
2024-09-25 CT - abdomen
2024-04-29 CT - abdomen
2024-01-24 CT - abdomen
….-..-..
2023-09-25 Patho - breast simple/partial mastectomy
2023-08-21 Patho - breast biopsy (no need margin)
2022-08-02 Patho - colon biopsy
[MedRec]
[chemotherapy]
[exam finding]
[MedRec]
[surgical operation]
[immunochemotherapy]
Patient Summary
Problem-Oriented Comments
Active Medication Review
[Assessing Thyroid Status and Treatment Needs]
This patient is taking self-carried Thyroid-S (T4 0.1mg) 1# QDAC.
The recent 3-month prescriptions in PharmaCloud do not include any thyroid-related medication such as levothyroxine (used for hypothyroidism) or antithyroid drugs (used for hyperthyroidism). There is also no lab data (e.g., TSH, FT4) to support hyperthyroidism.
Assessment and Next Steps:
[exam findings]
[MedRec]
[Key Summary]
This 75-year-old male has the following significant medical issues:
[Problem-Oriented Comments]
Follicular Lymphoma Staging and Management
Cognitive Decline
Chronic Conditions Management
[Active Medication Review]
Potential Issues:
[exam finding]
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
[Fluconazole Therapy for Candidemia in the Patient with Renal Impairment]
Patient Summary
This is a 60-year-old male with a history of:
Lab and Exam Evidence of Candida Infection
Diagnosis
Fluconazole Treatment
Loading Dose (Day 1)
Maintenance Dose (Day 2 Onwards)
Treatment Duration
Monitoring
Rationale
Contingency Plan
[Oral fluconazole administraion]
Patient Summary
Oral fluconazole considerations
Administration Plan
Rationale
Oncological Concerns
Renal Function and Nephrological Management
Hematological and Systemic Health
Infection and Inflammation
Nutrition and Supportive Care
Current Active Medications
[Medication Review]
[Analysis of Culture and Antibiogram]
Microorganisms Identified:
Recommendations for Antibiotic Therapy:
Monitoring and Follow-Up:
[lab data]
2024-08-09 Anti-HBc Nonreactive
2024-08-09 Anti-HBc Value 0.12 S/CO
2024-08-09 HBsAg Nonreactive
2024-08-09 HBsAg Value 0.74 S/CO
2024-08-09 Anti-HCV Nonreactive
2024-08-09 Anti-HCV Value 0.15 S/CO
2024-07-26 CA125 251.2 U/mL
2024-06-27 CA-125 (NM) 190.110 U/ml
2024-06-21 D-dimer 3206.00 ng/mL (FEU)
2023-10-25 ANA Centromere 1:1280
2023-10-23 Anti ENA (Ro,La) 2023-10-23 Anti-ENA SS-A (Ro) 24 EliA
U/ml
2023-10-23 Anti-ENA SS-B (La) <0.3 EliA U/ml
2023-10-23 ANCA 2023-10-23 PR3 Negative IU/ml
2023-10-23 PR3 Value <0.6 IU/ml
2023-10-23 MPO Negative
2023-10-23 MPO Value 2.5 IU/ml
2021-09-13 ANA Centromere; Cytoplasmic; 1:640
2021-05-24 ANA Centromere; Cytoplasmic; 1:640
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
Neutropenia Post-Chemotherapy
Chronic DVT Secondary to May-Thurner Syndrome
Cachexia and Anorexia in Metastatic Cancer
Active Medication Review
[taxol and carboplatin treatment cleared by lab results]
The patient is scheduled for treatment with Taxol and Carboplatin. Based on the blood cell count, electrolytes, liver, and renal function lab results from 2024-08-14, there is no evidence of contraindications.
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
Findings
Recommendations
[adjusting carboplatin and etoposide dosing for renal impairment]
The patient’s kidney function is trending downward.
With an eGFR of 37, if carboplatin is to be used, it is recommended to administer 75% of the usual dose for patients with a CrCl of 15 to 50 mL/minute.
For carboplatin AUC dosing using the Calvert formula, with the following patient details - age 79 years, weight 48.5 kg, creatinine 1.43 mg/dL, target AUC 4 mg/mL/min, and female gender - the calculated total dose is 197.7 mg.
Carboplatin AUC Dosing (Calvert) Calculator - 2024-08-20 - https://reference.medscape.com/calculator/169/carboplatin-auc-dosing-calvert
[tube feeding: options for administering Adapine and Const-K]
The half-life elimination of nifedipine varies among different populations: in healthy adults, it ranges from 2 to 5 hours; in individuals with cirrhosis, it extends to 7 hours; and in the elderly, it also reaches about 7 hours when using extended-release tablets.
Adapine S.R.F.C. (sustained-release film-coated) tablets are designed not to break down within the body, hence it is common to find the intact outer shell in the patient’s feces. The design of these tablets is meant to maintain steady drug levels in the bloodstream. Crushing these tablets will compromise their slow-release properties, making them ineffective at sustaining intended drug concentrations. If there is a need to continue using this medication, it should ideally be administered in divided doses to maintain stable blood levels.
Const-K 750mg is an extended-release tablet that delivers 10 mEq of potassium per tablet and is the only oral potassium supplement available in this hospital. If injectable potassium supplementation is not preferred, Const-K tablets can be crushed into fine particles for easier administration with water.
[evaluating the possibility of fungal infection in unresolved lung consolidation]
Neutropenia has largely resolved, yet CRP levels remain elevated while PCT has returned to normal ranges. Based on the comparison of CXR images from 2024-07-15 and 2024-07-05, patchy consolidation in the lower left lobe of the lung showed no improvement. If respiratory symptoms do not improve, a fungal infection could be suspected.
2024-07-17 WBC 3.41 x10^3/uL
2024-07-16 WBC 3.37 x10^3/uL
2024-07-15 WBC 0.61 x10^3/uL
2024-07-11 WBC 0.24 x10^3/uL
2024-07-08 WBC 0.26 x10^3/uL
2024-07-05 WBC 11.74 x10^3/uL
2024-07-01 WBC 3.41 x10^3/uL
2024-07-16 CRP 15.8 mg/dL
2024-07-15 CRP 15.3 mg/dL
2024-07-11 CRP 23.4 mg/dL
2024-07-08 CRP 14.3 mg/dL
2024-07-05 CRP 34.2 mg/dL
2024-07-16 Procalcitonin (PCT) 0.32 ng/mL
2024-07-15 Procalcitonin (PCT) 0.42 ng/mL
2024-07-11 Procalcitonin (PCT) 1.89 ng/mL
2024-07-08 Procalcitonin (PCT) 11.44 ng/mL
2024-07-05 Procalcitonin (PCT) 13.06 ng/mL
[carboplatin and etoposide administration and subsequent neutropenia]
Carboplatin and etoposide were administered on 2024-07-02, and neutropenia was noted on 2024-07-08. Given the elevated CRP and PCT levels, infection cannot be ruled out. Consequently, a 3-day course of Granocyte (lenograstim) was initiated on 2024-07-08. Blood transfusions were also conducted on 2024-07-01, 2024-07-05, and 2024-07-09. These measures are considered appropriate for the condition.
2024-07-08 Procalcitonin (PCT) 11.44 ng/mL
2024-07-05 Procalcitonin (PCT) 13.06 ng/mL
2024-07-08 CRP 14.3 mg/dL
2024-07-05 CRP 34.2 mg/dL
2024-07-08 WBC 0.26 x10^3/uL *
2024-07-05 WBC 11.74 x10^3/uL
2024-07-01 WBC 3.41 x10^3/uL
2024-06-30 WBC 3.76 x10^3/uL
2024-06-18 WBC 5.77 x10^3/uL
2024-06-17 WBC 5.93 x10^3/uL
2024-07-08 HGB 8.9 g/dL
2024-07-05 HGB 8.0 g/dL
2024-07-01 HGB 8.2 g/dL
2024-06-30 HGB 8.7 g/dL
2024-06-18 HGB 9.6 g/dL
2024-07-08 PLT 103 *10^3/uL
2024-07-05 PLT 227 *10^3/uL
2024-07-01 PLT 271 *10^3/uL
2024-06-30 PLT 253 *10^3/uL
2024-06-18 PLT 326 *10^3/uL
[exam finding]
[MedRec]
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
[thalassemia management and stable lab results, transition from ac to docetaxel treatment: neutropenia monitoring advised]
After four AC regimen treatments on 2024-07-01, 2024-07-20, 2024-08-10, and 2024-08-27, leukopenia events were frequently observed about one week after each session. The AC treatment cycle has now been completed, and the patient has begun treatment with docetaxel. It is recommended to continue monitoring for neutropenia.
The patient has a comorbidity of thalassemia, which manifests as anemia. Foliromin (ferrous sodium citrate 50mg) 1# BID has been prescribed for management. Electrolytes are balanced, and liver and kidney functions remain stable, with no need for dosage adjustments based on current conditions. No medication issues have been identified.
2024-09-13 HGB 8.5 g/dL
2024-09-13 WBC 7.90 x10^3/uL
2024-09-06 WBC 0.59 x10^3/uL ***
2024-08-27 WBC 8.20 x10^3/uL
2024-08-26 WBC 2.30 x10^3/uL *
2024-08-25 WBC 1.17 x10^3/uL **
2024-08-16 WBC 2.23 x10^3/uL *
2024-08-10 WBC 4.15 x10^3/uL
2024-07-26 WBC 3.71 x10^3/uL
2024-07-20 WBC 3.26 x10^3/uL
2024-07-08 WBC 2.90 x10^3/uL *
2024-06-29 WBC 11.48 x10^3/uL
[exam findings]
[consultation]
[chemotherapy]
2024-12-10 - NS 50mL 15min + OBI-992 4mg/kg 336mg NS 216.4mL 3hr + NS 30mL 5min + NS 200mL 30min (OBI-992: anti-TROP2 ADC)
2024-10-30 - etoposide 40mg/m2 80mg NS 250mL 30min + epirubicin 10mg/m2 20mg NS 250mL 10min + leucovorin 120mg/m2 230mg NS 250mL 24hr + fluorouracil 2200mg/m2 4300mg NS 170mL 24hr (infusor) (EEPFL)
2024-10-16 - etoposide 40mg/m2 80mg NS 250mL 30min + epirubicin 10mg/m2 20mg NS 250mL 10min + leucovorin 120mg/m2 230mg NS 250mL 24hr + fluorouracil 2200mg/m2 4300mg NS 170mL 24hr (infusor) (EEPFL)
2024-09-25 - etoposide 40mg/m2 80mg NS 250mL 30min + epirubicin 10mg/m2 20mg NS 250mL 10min + leucovorin 120mg/m2 230mg NS 250mL 24hr + fluorouracil 2200mg/m2 4300mg NS 170mL 24hr (infusor) (EEPFL)
2024-09-11 - etoposide 40mg/m2 80mg NS 250mL 30min + epirubicin 10mg/m2 20mg NS 250mL 10min + leucovorin 120mg/m2 230mg NS 250mL 24hr + fluorouracil 2200mg/m2 4300mg NS 170mL 24hr (infusor) (EEPFL)
2024-08-28 - etoposide 40mg/m2 80mg NS 250mL 30min + epirubicin 10mg/m2 20mg NS 250mL 10min + leucovorin 120mg/m2 230mg NS 250mL 24hr + fluorouracil 2200mg/m2 4300mg NS 170mL 24hr (infusor) (EEPFL)
2024-08-14 - etoposide 40mg/m2 80mg NS 250mL 30min + epirubicin 10mg/m2 20mg NS 250mL 10min + leucovorin 120mg/m2 230mg NS 250mL 24hr + fluorouracil 2200mg/m2 4300mg NS 170mL 24hr (infusor) (EEPFL)
2024-07-31 - etoposide 40mg/m2 75mg NS 250mL 30min + epirubicin 10mg/m2 20mg NS 250mL 10min + leucovorin 120mg/m2 230mg NS 250mL 24hr + fluorouracil 2200mg/m2 4200mg NS 170mL 24hr (infusor) (EEPFL)
2024-07-17 - etoposide 40mg/m2 75mg NS 250mL 30min + epirubicin 10mg/m2 20mg NS 250mL 10min + leucovorin 120mg/m2 230mg NS 250mL 24hr + fluorouracil 2200mg/m2 4200mg NS 170mL 24hr (infusor) (EEPFL)
2024-07-03 - etoposide 40mg/m2 75mg NS 250mL 30min + epirubicin 10mg/m2 20mg NS 250mL 10min + leucovorin 120mg/m2 230mg NS 250mL 24hr + fluorouracil 2200mg/m2 4200mg NS 170mL 24hr (infusor) (EEPFL)
2024-06-19 - etoposide 40mg/m2 75mg NS 250mL 30min + epirubicin 10mg/m2 20mg NS 250mL 10min + leucovorin 120mg/m2 230mg NS 250mL 24hr + fluorouracil 2200mg/m2 4200mg NS 170mL 24hr (infusor) (EEPFL)
2024-06-04 - etoposide 40mg/m2 75mg NS 250mL 30min + epirubicin 10mg/m2 20mg NS 250mL 10min + cisplatin 25mg/m2 45mg NS 500mL 24hr (Y-sited Covorin 5-FU) + leucovorin 120mg/m2 230mg NS 250mL 24hr (Y-sited Kemoplat 5-FU) + fluorouracil 2200mg/m2 4200mg NS 500mL 24hr (Y-sited Covorin Kemoplat) (EEPFL)
….-..-..
2022-11-08 - gemcitabine 800mg/2 1600mg 30min + oxaliplatin 85mg/m2 160mg 2hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2000mg/m2 4000mg 48hr
2022-10-25 - gemcitabine 800mg/2 1600mg 30min + oxaliplatin 85mg/m2 160mg 2hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2000mg/m2 4000mg 48hr
2022-09-28 - gemcitabine 800mg/2 1600mg 30min + oxaliplatin 85mg/m2 150mg 2hr + leucovorin 300mg/m2 570mg 2hr + fluorouracil 2000mg/m2 3800mg 48hr
2022-09-13 - gemcitabine 800mg/2 1600mg 30min + oxaliplatin 85mg/m2 150mg 2hr + leucovorin 300mg/m2 570mg 2hr + fluorouracil 2000mg/m2 3800mg 48hr
2022-08-29 - gemcitabine 800mg/2 1600mg 30min + oxaliplatin 85mg/m2 150mg 2hr + leucovorin 300mg/m2 570mg 2hr + fluorouracil 2000mg/m2 3800mg 48hr
GOLF regimen ref:
[Key Summary]
The patient is a 58-year-old male with advanced duodenal adenocarcinoma (cT4N2M1, Stage IV) complicated by:
Laboratory data:
[Problem Review]
Objective
Assessment
Recommendations
[Medication Review]
Key Medications
Appropriateness Review
The GOLF regimen was introduced as a neoadjuvant treatment since late August 2022 with the aim of downstaging the tumor. The CT (2022-11-16) revealed that the adenocarcinoma of the duodenal bulb showed a mild increase in size and that the metastatic nodes displayed a decrease in size. There appears to be a greater likelihood that this will improve the feasibility of the surgery.
The decreased CA199 marker also served as a side evidence that the regimen is still effective.
Data available indicate stable vital signs, and there is no problem with the active prescription.
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
[Evaluation of Anemia]
Current Status of Anemia (2024-12-10):
Relevant Historical and Clinical Context:
Possible Contributing Factors to Anemia:
Recent Trends:
Risk Assessment:
Recommendations:
Further Tests:
[Evaluation of Treatment Effectiveness]
Primary Disease (Hodgkin Lymphoma):
Systemic and Nutritional Health:
Recommendations
Current Findings and Management Needs:
[advanced Hodgkin lymphoma: treatment strategies and options]
The NCCN guidelines (20241022) provide several recommendations for advanced-stage Hodgkin lymphoma (Stage III-IV), highlighting some options that might be appropriate for this patient:
Given the patient’s advanced age and current comorbidities, selecting a regimen that balances efficacy and manageable toxicity, such as Brentuximab + AVD or Nivolumab + AVD, could be suitable.
[exam finding]
[MedRec]
[exam finding]
[MedRec]
[consultation]
[Key Summary]
[Problem List]
[Medication Review]
Hydralazine HCl (Brand: Apolin) 25 mg PRN Q6H (for BP control)
Denosumab (for bone metastases)
Gemcitabine + Cisplatin (Chemotherapy for cholangiocarcinoma/metastatic disease)
Nebivolol 5 mg QD (for hypertension)
Metformin 500 mg BID (for diabetes)
Oxybutynin ER 5 mg QD (for overactive bladder)
Tramadol/Acetaminophen 37.5/325 mg PRN Q6H (for pain)
Folacin (Folic Acid) 5 mg QD
Exforge (Amlodipine/Valsartan) 5 mg/160 mg QD (for hypertension)
[exam finding]
2024-11-01 KUB
2024-10-29 Upper GI & Small Intestine
2024-10-26 LUB
2024-10-26 CXR
2024-10-16 CXR
2024-10-14 SONO - chest
2024-10-12 CT - abdomen
2024-09-10 KUB
2024-08-12 KUB
2024-07-12 Ascites tapping
2024-06-13 CXR
2024-06-13 Pure Tone Audiometry, PTA
2024-06-12 CXR
2024-06-12 ECG
2024-05-31 Ascites tapping
2024-04-01 Patho - peritoneum biopsy
2024-03-29 ECG
2024-03-19 Whole body PET scan
2024-02-06 Ascites tapping
2024-01-25 ECG
2024-01-25 Ascites tapping
2024-01-25 SONO - abdomen
2024-01-22 CT - abdomen
2024-01-17 SONO - gynecology
2024-01-12 SONO - abdomen
2023-06-08 Ascites tapping
2023-06-08 SONO - abdomen
2023-05-15 PET
2023-05-05 SONO - gynecology
2023-04-27 Patho - omentum biopsy
2023-04-27 Patho - peritoneum biopsy
2023-04-25 ECG
2023-04-25 Colonoscopy
2023-04-24 SONO - gynecology
2023-04-22 Ascites tapping
2023-04-22 SONO - abdomen
2023-04-21 CT - abdomen
2023-02-03 SONO - abdomen
2023-01-16 SONO - breast
2022-12-30 CT - abdomen, pelvis
[MedRec]
[consultation]
[immunochemotherapy]
Key Findings:
Management Recommendations:
The patient is a 37-year-old female with advanced right lower lung cancer (adenosquamous carcinoma, Stage IVb) with metastases to the skull, pleura, left lung, spine, and multiple bones.
[Intervention Review]
The patient has extensive bone metastases and a history of compression fractures treated with vertebroplasty and laminectomy.
Current Status:
Recommendation:
The patient has Grade 2 anemia (HGB: 8.3 g/dL), likely due to chemotherapy and chronic disease.
Current Status:
Recommendation:
The patient has recurrent malignant effusion and bilateral pneumonitis.
Current Status:
Recommendation:
Medication Review
[tube feeding]
All the oral medications on the active list are suitable for tube feeding.
Nutritional Support
Monitoring Fluid and Electrolyte Balance
Tube feeding can predispose patients to dehydration or electrolyte imbalances, especially in patients with concurrent chemotherapy and high-output losses (e.g., from malignant pleural effusion).
Current Status:
Recommendations:
Risk of Aspiration
Aspiration is a serious concern in tube-fed patients, especially with pleural effusion and bilateral pneumonitis.
Recommendations:
Complications of Tube Feeding
Specific Adjustments for the Patient
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
2024-12-20 - oxaliplatin 50mg/m2 65mg D5W 250mL 2hr
2024-12-04 - oxaliplatin 50mg/m2 65mg D5W 250mL 2hr
2024-11-15 - oxaliplatin 50mg/m2 65mg D5W 250mL 2hr
2024-10-25 - leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 400mg/m2 560mg NS 100mL 10min + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr
2024-10-11 - leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 400mg/m2 560mg NS 100mL 10min + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr
2024-09-03 - bevacizumab 5mg/kg 200mg NS 140mL 90min + oxaliplatin 50mg/m2 65mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr
2024-08-19 - leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2800mg/m2 3900mg NS 500mL 46hr
[Patient Summary]
The patient, a 67-year-old female, has a history of advanced rectosigmoid junction adenocarcinoma (pT4aN1bM1c, Stage IV), with documented peritoneal carcinomatosis and metastases to the lungs, liver, and spleen. She has undergone multiple surgical interventions, including a colostomy (2023-07-27), and has experienced complications such as rectovaginal fistula, ascites, ileocolostomy herniation, and small bowel obstruction (KUB findings on 2025-01-10). Her chemotherapy has included regimens like XELOX (capecitabine and oxaliplatin) and FOLFOX, with intervals of stable disease, tumor regression (CT findings on 2024-11-19), and tolerable side effects. However, complications such as infection, gastrointestinal symptoms, and poor nutritional status have necessitated hospitalizations.
[Problem Comments]
Problem 1: Metastatic Rectosigmoid Junction Adenocarcinoma
Problem 2: Small Bowel Obstruction
Problem 3: Nutritional Deficiency and Cachexia
Problem 4: Rectovaginal Fistula
Problem 5: Hyponatremia
Problem #1: Adenocarcinoma of the Rectosigmoid Junction with Peritoneal Carcinomatosis and Metastases
Problem #2: Recto-Vaginal Fistula
Problem #3: Cachexia and Poor Nutrition
Problem #4: Hyponatremia
Problem #5: Chemotherapy-Associated Anemia
Problem #6: Pain Management
[fluconazole dosing strategy for candida albicans in low-weight patient]
Sputum culture results identified Klebsiella pneumoniae and Candida albicans. The former has been treated with Tapimycin (piperacillin/tazobactam), to which the Klebsiella is sensitive, and fluconazole was prescribed this evening for the Candida infection.
Directed Therapy (Candida albicans identified): Fluconazole is recommended at a loading dose of 800 mg (12 mg/kg), followed by 400 mg IV/PO daily once blood cultures have cleared and the patient is clinically stable.
The patient weighs 46.5 kg, which approximates a loading dose of 558 mg (equivalent to 3 to 4 capsules of 150 mg each), followed by a maintenance dose of 2 capsules (300 mg) daily.
[exam findings]
2024-12-01, -11-11 CXR
2024-11-21 CT - chest
2024-11-08 Patho - bronchus biopsy
2024-11-08 Bronchoscopy
2024-11-05 Upper GI Series
2024-11-02 CT - chest
2024-11-02 Esophagogastroduodenoscopy, EGD
2024-10-07 CXR
2024-09-18 SONO - abdomen
2024-08-21 CT - chest
2024-08-07 CXR
2024-06-26 SONO - abdomen
2024-05-20, -05-19, -05-05 CXR
2024-05-09 Bronchoscopy
2024-05-09 Miniprobe Endoscopic Ultrasound
2024-05-08 Tc-99m MDP bone scan
2024-05-07 PET
2024-05-06 MRI - brain
2024-05-06
2024-05-06 2D transthoracic echocardiography
2024-04-24 Bladder Sonography
2024-04-24 Uroflowmetry
2024-04-23 Microsonography
2024-04-12 CT - chest
2024-04-10 Patho - esophageal biopsy
2024-04-03 SONO - abdomen
2024-03-27 Microsonography
2024-01-10 SONO - abdomen
2023-10-26 MRI - prostate
2023-10-23 CT - abdomen
2023-10-18 SONO - abdomen
2023-10-16 Tc-99m MDP bone scan
2023-10-03 Patho - prostate needle biopsy
2023-10-03 Patho - prostate needle biopsy
2023-07-26 SONO - abdomen
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
Clinical Conditions
Key Concerns and Recommendations
[Anemia]
Laboratory Evidence of Anemia - Recent hematological parameters reveal significant anemia:
Likely Etiologies
Diagnostic and Clinical Correlations
Management Recommendations
Patient Overview - This 68-year-old male patient has a complex medical history, including:
Recent Clinical Findings
Anemia and Blood Findings - This patient exhibits chronic anemia characterized by:
Anemia Analysis and Recommendations
Comorbid Conditions and Management Considerations
Medications Review for Nephrotoxicity, Hepatic Considerations, and Interactions (below not posted)
[persistent anemia and multiple transfusions]
The patient’s hemoglobin (HGB) levels have remained below the reference range throughout the year.
Blood transfusions were administered on 2024-05-19, 2024-07-02, 2024-07-06, 2024-07-12, 2024-07-18, 2024-07-25, 2024-07-29, 2024-09-05, and 2024-10-07.
If future transfusions are not viable, it may be necessary to consider alternative treatment options.
[correcting hyponatremia, hypomagnesemia: adding albumin support]
Hyponatremia, hypomagnesemia, and hypoalbuminemia have been observed in the patient.
MgSO4 and normal saline are currently being administered.
Considering the low albumin levels, albumin supplementation or more intensive nutritional support may be appropriate to address the deficiencies.
[blood transfusion for anemia with mild lab abnormalities]
Anemia was noted on 2024-09-05, with HGB at 8.4 g/dL, prompting an LPRBC transfusion on the same day. Other lab results revealed mild hyponatremia, hypoalbuminemia, and a slightly elevated bilirubin level. No medication reconciliation issues were identified.
[anemia progression despite blood transfusion]
This patient has been receiving the PF regimen since 2024-05-29, and has since experienced a significant decline in HGB, reaching grade 3 (severe) anemia by July. The PF regimen, which includes cisplatin and fluorouracil, is associated with anemia incidences of up to 40% for cisplatin and unspecified rates for fluorouracil.
Although the sharp decline in HGB occurred after chemotherapy, suggesting a possible causal relationship, the patient’s HGB levels had already started decreasing before starting the PF regimen. Given that the latest PF regimen administration was at least a month ago, HGB levels would typically be expected to recover; however, the patient’s HGB has been continuously decreasing.
The patient received a blood transfusion on 2024-07-02 (the same day as the 2nd session of chemotherapy). Despite the transfusion, HGB levels have continued to fall. If the patient cannot regain hematopoietic ability or tolerate frequent transfusions (if needed), it may be necessary to further reduce the dosage or change the regimen.
[deteriorating liver function and treatment options]
The patient’s liver function is deteriorating, and BaoGan (silymarin) is currently being used. Given that BDI is increasing and is the main contributor to elevated BTI, adding Uliden (ursodeoxycholic acid) might be beneficial if clinically appropriate.
2024-07-02 ALT 90 U/L
2024-06-24 ALT 21 U/L
2024-07-02 AST 113 U/L
2024-06-24 AST 24 U/L
2024-07-02 Bilirubin direct 0.35 mg/dL
2024-06-03 Bilirubin direct 0.24 mg/dL
2024-05-29 Bilirubin direct 0.21 mg/dL
[exam findings]
[MedRec]
[chemotherapy]
UFT (tegafur 100mg, uracil 224 mg)
[Simple Suspension Method (SSM) for Medication Tube Feeding]
SSM is a technique used to administer medications to patients who are unable to swallow, such as those receiving enteral tube feeding. It involves suspending medications in warm water to dissolve or disperse them, allowing for easier administration through a feeding tube.
Steps Involved in SSM:
Advantages of SSM:
Considerations:
[tube feeding - UFT handling precautions]
UFT (tegafur and uracil) is cytotoxic, posing a potential health hazard if directly contacted. Therefore, it is strongly recommended that healthcare personnel follow strict safety protocols when handling UFT granules to prevent exposure.
[lab data]
2023-08-10 Anti-β2-glycoprotein-I Ab 0.6 U/mL
2023-08-10 Anti-cardiolopin IgG 0.7 GPL-U/mL
2023-08-10 Anti-cardiolipin IgM 1.3 MPL-U/mL
2023-08-08 CEA (NM) 89.031 ng/ml
2023-08-07 HBsAg Nonreactive
2023-08-07 HBsAg (Value) 0.36 S/CO
2023-08-07 Anti-HBc Reactive
2023-08-07 Anti-HBc-Value 6.47 S/CO
2023-08-07 Anti-HCV Nonreactive
2023-08-07 Anti-HCV Value 0.09 S/CO
2023-08-07 CEA 96.78 ng/mL
2023-08-07 CA199 29.24 U/mL
2023-08-07 D-dimer > 10000.00 ng/mL(FEU)
2023-08-07 PT 11.1 sec
2023-08-07 INR 1.08
2023-08-07 APTT 25.7 sec
2023-08-07 Fibrinogen(quantita) 364.4 mg/dL
2023-08-04 Alkaline phosphatase 931 U/L
[exam findings]
[MedRec]
[chemotherapy]
2023-09-01 ~ 2023-12-03 - Iressa (gefitinib 250mg) 1# QD
Clinical Summary
Recommendations:
Prognostic Considerations:
[Context of Switching to Pemetrexed + Carboplatin]
Implications of Switching
Next Steps
[exam finding]
[MedRec]
[consultation]
[Key Clinical Findings and Current Status]
[Current Lab Evidence]
[Management Recommendations]
Oncologic Management
Renal Support
Diabetes Management
Nutritional Optimization
Symptom Management
Palliative and Supportive Care
Key Clinical Findings and Current Status
Would you like a more detailed treatment timeline or further clarification?
[MedRec]
[consultation]
Haloperidol 5mg 0.5amp PRNQ6H IM if agitated
Titrate Utapine according to response, maximum 150mg/day
Delirium recovery behavioral modification
If the patient is bedridden during the day, elevate the head of the bed to a sitting position to prevent drowsiness.
Encourage wheelchair mobility and active rehabilitation for most of the day.
Provide orientation information regularly: remind the patient of the date, location, and surrounding people and things.
Maintain a day-night cycle by using natural light from windows and artificial light from lamps.
Arrange PSY OPD follow-up after discharge
As long as reposition the patient regularly, her wound won’t open up any further.
Please continue to change her wet dressing daily. Be careful not to stuff the gauze into the wound, as this could cause it to open wider.
We will not remove the stitches for now. Leaving the stitches in for more than a month will not cause infection and can actually prevent the wound from reopening.
Please call us before she is discharged or if her wound worsens.
[MedRec]
[lab data]
[exam findings]
[MedRec]
[consultation]
[immunochemotherapy]
Key Findings
Recommendations
Clinical Follow-Up Plan
The patient recently renewed her repeat prescription for Diovan (valsartan) to manage her primary hypertension at a local pharmacy on 2023-07-19. This medication is currently listed in the active formulary, and no reconciliation issues have been identified.
The most recent medical image was scaned on 2023-05-05 (abdomen CT). An update may be beneficial to reassess the current disease status.
[exam finding]
[chemotherapy]
Chemotherapy regimens for initial treatment of multiple myeloma: Bortezomib, thalidomide, and dexamethasone (VTd) induction therapy - 2024-11-29 - https://www.uptodate.com/contents/image?imageKey=ONC/101205
[Grade 3 Nausea and Grade 3 Anorexia]
For the Grade 3 nausea and Grade 3 anorexia (loss of appetite) in this patient, both conditions significantly impair oral intake, potentially causing severe malnutrition, weight loss, and a need for aggressive nutritional support. Here’s a detailed analysis and recommendations:
Current Issues
Clinical Concerns
Recommendations for Management
Anti-Nausea Management
Appetite Stimulation
Electrolyte and Fluid Management
Monitoring and Follow-Up
Long-Term Considerations
[Findings and Recommendations]
Clinical Findings
Management Strategies
[Medication Review]
Here is a detailed review of the current active medications for this patient based on their pharmacological actions, potential benefits, adverse effects, and specific considerations in the context of the patient’s medical history (multiple myeloma, CKD, anemia, and ongoing chemotherapy with bortezomib):
Summary of Suggestions:
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
Anemia and Treatment Adverse Reaction:
Pancreatic Cancer and Chemotherapy:
Electrolyte Imbalances:
Current Status and Monitoring:
[Rising Tumor Markers Indicate Potential Pancreatic Cancer Progression]
Oncologic Disease Progression
Potential Problems to be considered
[Advanced Pancreatic Cancer: Refractory to Multiple Lines of Therapy]
Treatment Summary:
Recommendations Based on Prior Treatment History:
[Onivyde Fu/Lv regimen: first administration review, follow-up needed for elevated liver enzymes]
Onivyde (liposomal irinotecan) NALIRIFOX was not used as the initial treatment regimen for this patient. When using the Onivyde Fu/Lv regimen after gemcitabine treatment, the recommended administration steps are as follows: (Ref: https://www.onivyde.com/en-us/for-patients/learn-about-onivyde/how-onivyde-is-given)
Onivyde should be administered IV at 70 mg/m² over 90 minutes, with leucovorin given over 30 minutes and fluorouracil over 46 hours, once every 2 weeks; continue until disease progression or unacceptable toxicity occurs.
There were no issues with the first administration of the Onivyde Fu/Lv regimen, which began on 2024-08-26. Additionally, please note that liver enzyme levels are elevated, warranting follow-up.
2024-08-26 ALT 46 U/L
2024-08-21 ALT 24 U/L
2024-08-06 ALT 13 U/L
2024-08-26 AST 40 U/L
2024-08-21 AST 27 U/L
2024-08-06 AST 18 U/L
[electrolyte correction and chemotherapy cancellation]
Hypoalbuminemia, hypokalemia, and hypocalcemia were noted. Plasbumin (human albumin), Bfluid (amino acids), and both oral and injectable KCl have been administered. The balancing process shows no issues identified. The scheduled Onivyde + 5-FU prescription has been cancelled.
[tracking HGB decline during ongoing chemotherapy]
According to HIS5 records, the patient has undergone chemotherapy every month since Feb 2023, except for the period between Sep and Dec 2023.
Lab results show a downward trend in HGB levels this year, decreasing from a high of 12 g/dL in Jan to below 8 g/dL recently, suggesting that chemotherapy has likely contributed to worsening anemia.
A transfusion was appropriately administered on 2024-08-21, when HGB reached its lowest point. An improvement in HGB levels is expected.
All repeat prescriptions issued by our gastroenterologist on 2023-05-17, cardiologist on 2023-06-06, and general surgeon on 2023-07-25 have been consistently refilled. These medications have been added to the active medication list, and no reconciliation issues have been identified.
[exam finding]
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
[Key Findings]
Clinical Data Highlights:
Medication Review
[Recommendations]
Lab & Diagnostic Workup:
Management of Anemia:
Supportive Care for Comorbidities:
Clinical Improvement Strategies:
Monitoring and Follow-Up:
[Addressing nutritional needs and accurate weight tracking]
The weight records indicate that from 2024-09-10 to 2024-10-23, there were nine data points, all showing 59.8 kg. However, by 2024-11-05, the weight dropped significantly to 47.9 kg. Given that chemotherapy started in 2024-08, a gradual weight decline might be expected. The sudden drop in the last data point may be due to repeated, non-measured entries during the prior period, possibly resulting from copying previous values rather than actual measurements.
A dietitian consultation on 2024-11-06 identified the following nutritional diagnoses: insufficient protein intake; increased nutritional needs due to long-term metabolic conditions, malabsorption, and age-related factors; and protein intake not meeting estimated requirements. The final assessment recommended intervention with a caloric intake of 1700 kcal and 70g of protein.
Regarding medications, adding an appetite stimulant, such as megestrol, could be considered to improve appetite.
[Recommendations for the Patient with Esophageal Cancer and Cardiac Complications]
Patient Summary:
Current Treatment and Management:
Recommendations:
[G-CSF options for leukopenia following PF regimen treatments]
Leukopenia was noted 2 to 3 weeks following the second session of the PF regimen on 2024-09-05. If similar trends are anticipated after the third session, short- or long-acting G-CSF could be considered as a prophylactic measure.
[lab data]
2024-10-04 IgG4 106 mg/dL
2024-10-04 HBsAg (NM) Positive
2024-10-04 HBsAg Value (NM) 1548.000
2024-10-04 Anti-HBc IgM (NM) Negative
2024-10-04 Anti-HBc IgM Value (NM) 0.063
2024-10-02 HBV DNA-PCR (quantative) 516 IU/mL
2024-10-01 Anti-HBs 69.07 mIU/mL
2024-10-01 Anti-HBc Reactive
2024-10-01 Anti-HBc Value 6.68 S/CO
2024-10-01 HBeAg Nonreactive
2024-10-01 HBeAg Value 0.314 S/CO
[exam finding]
[MedRec]
[chemotherapy]
[Findings and Recommendations]
Key Findings:
Medication Review:
Recommended Tests:
Clinical Improvements:
[exam finding]
[MedRec]
[exam finding]
[MedRec]
[tube feeding]
Due to its formulation, Harnalidge OCAS (tamsulosin 0.4 mg) is not suitable for administration via a feeding tube. Urief (silodosin 8 mg) is a more appropriate alternative for managing the patient’s condition.
[Findings and Suggestions]
Patient Key Findings:
Management Suggestions:
Glucose hypermetabolism in the left upper lung pleura-based lesion and in regional lymph nodes (hilar, mediastinal, and supraclavicular nodes).
- Left upper lobe lesion characteristics and PET imaging favor non-small cell lung cancer (NSCLC), particularly adenocarcinoma, as it is the most common NSCLC subtype in pleural-based lesions.
- No Small Cell Features Documented:Small cell lung cancer (SCLC) tends to have a more central location in the lungs and rapidly progressive symptoms with paraneoplastic syndromes (e.g., SIADH, Lambert-Eaton). None of these findings are documented in this case.
- Imaging findings (pleural-based lesions, bone, and brain metastases) are more consistent with NSCLC, as SCLC would typically show rapid, diffuse metastasis but less pleural involvement.
- Biopsy Pathology:No lung biopsy pathology results were explicitly in records. The absence of pathology results leaves the lung cancer subtype unconfirmed, but the presentation and imaging findings lean heavily toward NSCLC. - Molecular testing for actionable mutations (EGFR, ALK, ROS1, etc.). - Systemic therapy: Platinum-based doublets or targeted therapy (depending on molecular findings) for palliation.
[exam finding]
[MedRec]
[surgical operation]
[immunochemotherapy]
[Findings and Recommendations]
Key Clinical Findings:
Treatment Review:
Recommendations and Clinical Suggestions:
[MedRec]
[immunochemotherapy]
2024-11-19 - atezolizumab 1200mg NS 250mL 1hr
2024-11-18 - carboplatin AUC 5 750mg NS 250mL 2hr + [KCl 15% 5mL NS 500mL 2hr + KCl 15% 5mL D5W 500mL 2hr] (post carboplatin)
2024-10-21 - atezolizumab 1200mg NS 250mL 1hr
2024-09-16 - atezolizumab 1200mg NS 250mL 1hr
2024-09-14 - carboplatin AUC 5 750mg NS 250mL 2hr + [KCl 15% 5mL NS 500mL 2hr + KCl 15% 5mL D5W 500mL 2hr] (post carboplatin)
2024-09-11 - etoposide 100mg/m2 100mg NS 500mL 2hr D1-3
2024-08-15 - etoposide 100mg/m2 100mg NS 500mL 2hr D1-3
2024-08-14 - carboplatin AUC 5 750mg NS 250mL 2hr
2024-08-13 - atezolizumab 1200mg NS 250mL 1hr
2024-07-22 - etoposide 150mg NS 500mL 2hr D2-3 + cisplatin 30mg NS 200mL 2hr D2-3
2024-05-31 - durvalumab 240mg NS 100mL 1hr
2024-05-24 - carboplatin AUC 5 250mg NS 250mL 2hr
2024-05-22 - etoposide 100mg/m2 100mg NS 500mL 2hr (60%)
[Comments and Recommendations on Thrombocytopenia]
Key Findings Related to Thrombocytopenia:
Recommendations for Management:
Proposed Follow-Up Plan:
[exam finding]
[MedRec]
[consultation]
[immunochemotherapy]
Summary of Key Clinical Features
Treatment Suggestion and Rationale
[exam finding]
[chemotherapy]
[lab data]
2024-06-25 Anti-HBc Nonreactive
2024-06-25 Anti-HBc Value 0.17 S/CO
2024-05-07 HBsAg Nonreactive
2024-05-07 HBsAg Value 0.56 S/CO
2024-05-07 Anti-HCV Nonreactive
2024-05-07 Anti-HCV Value 0.10 S/CO
2024-05-07 Anti-HBs >1000.00 mIU/mL
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
[Observed ANC Nadir Post-Chemotherapy]
2024-07-04 TCH Administration (Cycle 1):
2024-07-27 (Cycle 2):
2024-08-21 (Cycle 3):
2024-09-14 (Cycle 4):
2024-10-22 (Cycle 5):
[Neutropenia Trends and Relationship with TCH Regimen]
Key Findings from Neutropenia Patterns Post-Chemotherapy:
Trends:
Risk Stratification
[Recommendations for Neutropenia]
Chemotherapy Dose Management
Neutropenia Management
Monitoring
Supportive Care
[Clinical Assessment and Comprehensive Plan]
Key Findings:
Current Issues and Management Recommendations
[exam finding]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
[Findings and Recommendations]
Primary Diagnosis
Review of Current Treatment Plan
Clinical Issues and Recommendations
Prognosis
Actionable Recommendations
[lab data]
2023-04-17 HBsAg Nonreactive
2023-04-17 HBsAg Value 0.49 S/CO
2023-04-17 Anti-HBc Reactive
2023-04-17 Anti-HBc Value 6.95 S/CO
2023-04-17 Anti-HBc IgM Nonreactive
2023-04-17 Anti-HBc IgM Value 0.15 S/CO
[exam finding]
[MedRec]
[consultation]
[chemotherapy]
[Insights and Recommendations for the Current Patient Undergoing Allo-PBSCT]
Key Summary
Current Issues:
Recommendations:
Laboratory Monitoring
Guideline Integration
[Minutes of Interprofessional Practice (IPP) and Family Meeting]
On 2024-11-18, from 15:00 to 16:15, the patient’s attending physician, Dr. Gao, convened an Interprofessional Practice (IPP) and Family Meeting.
The patient and his two daughters participated. Dr. Gao provided a detailed explanation of the patient’s condition, the expected outcomes of allogeneic hematopoietic stem cell transplantation (Allo-HSCT), and the associated risks.
The patient raised questions about the five-year survival rate and post-transplantation precautions, which Dr. Gao addressed comprehensively. During the meeting, neither the patient nor the family raised any questions for other professionals.
At the conclusion of the meeting, the patient signed a consent form, agreeing to proceed with the allogeneic HSCT.
Please be aware that the patient’s renal function has been declining over the past three days. At present, there’s no need for a dose adjustment, but it’s crucial to continue monitoring closely.
Lab data has shown signs of recovery in the patient’s WBC count. However, the PLT count continues to hover at relatively low levels, never reaching 100K/uL.
Indications for platelet transfusion include actively bleeding patients with thrombocytopenia who should receive immediate platelet transfusion to maintain platelet counts above 50K/uL in most bleeding situations, including disseminated intravascular coagulation (DIC), and above 100K/uL in central nervous system bleeding.
Unfortunately, there are no perfect tests to predict spontaneous bleeding. Studies in patients with thrombocytopenia suggest that spontaneous bleeding can occur even with platelet counts above 50K/uL. However, bleeding is much more likely when the platelet count falls below 5K/uL. For individuals with platelet counts between 5K and 50K/uL, clinical observations may be useful in deciding whether to transfuse platelets.
[chemotherapy]
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
Chemotherapy regimens for multiple myeloma: Bortezomib (Velcade), lenalidomide (Revlimid), and “low dose” dexamethasone (VRd) - 2024-10-30 - https://www.uptodate.com/contents/image?imageKey=ONC%2F91054
[tube feeding - Proper administration of controlled-release and enteric-coated medications]
OxyContin (oxycodone 10 mg) is a controlled-release tablet. According to the medication guide, patients should swallow the tablet whole with a sufficient amount of water. The tablet must not be moistened, soaked, or licked before swallowing. Crushing, chewing, or dissolving the tablet is strictly prohibited, as it may result in uncontrolled release of oxycodone, risking a potentially fatal overdose.
Dulcolax (bisacodyl 5 mg) is an enteric-coated tablet, so breaking or crushing it is not recommended for tube feeding.
[considering dexamethasone reintroduction in VRd therapy]
VRd is a common treatment regimen for multiple myeloma. It consists of three drugs:
Starting a VRd cycle requires an ANC ≥ 1000/microL and platelets ≥ 70,000/microL. If platelets fall below 50,000/microL or ANC drops below 1000/microL on day 15, withhold that day’s bortezomib dose. If doses are repeatedly withheld, reduce the bortezomib level and decrease lenalidomide by 5 mg daily. Growth factor support may be provided on day 8 for prolonged ANC < 500/microL.
There are no recent dexamethasone records in PharmaCloud. Reintroducing dexamethasone (40 mg) on days 1, 8, and 15 could complete the VRd regimen.
Regarding anemia in multiple myeloma:
Anemia is a common complication in multiple myeloma, occurring in about 65% of patients at diagnosis1.
Multiple myeloma can cause anemia by:
Anemia in multiple myeloma patients often improves as the myeloma is treated effectively2. As myeloma cells die off, healthy cells can normalize red blood cell levels.
Some myeloma treatments, including Revlimid (part of the VRd regimen), can potentially cause or worsen anemia as a side effect2.
Treatment options for anemia in myeloma patients include:
Treating the underlying multiple myeloma with regimens like VRd is often the primary way to address anemia in these patients.
If anemia persists after myeloma treatment, other causes should be considered, such as iron deficiency2.
Citations:
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[Optimizing Cefepime Dosing in Acute Kidney Injury]
Lab data:
2024-11-13 Creatinine 3.06 mg/dL
2024-11-12 Creatinine 2.70 mg/dL
2024-11-11 Creatinine 2.33 mg/dL
2024-11-09 Creatinine 2.01 mg/dL
2024-11-05 Creatinine 1.52 mg/dL
2024-10-29 Creatinine 1.10 mg/dL
2024-11-13 eGFR 21.42 ml/min/1.73m^2
2024-11-12 eGFR 24.74 ml/min/1.73m^2
2024-11-11 eGFR 29.33 ml/min/1.73m^2
2024-11-09 eGFR 34.78 ml/min/1.73m^2
2024-11-05 eGFR 48.02 ml/min/1.73m^2
2024-10-29 eGFR 69.74 ml/min/1.73m^2
The patient’s renal function is declining, as shown by the steady rise in serum creatinine levels and corresponding decrease in estimated glomerular filtration rate (eGFR). Over the past two weeks, the eGFR has dropped from 69.74 ml/min/1.73m² on 2024-10-29 to 21.42 ml/min/1.73m² on 2024-11-13. This significant reduction in renal function suggests that the dosing of cefepime should be reassessed to prevent potential accumulation and toxicity, given cefepime’s primarily renal clearance.
Recommendations:
Adjust Cefepime Dose:
Renal Function Monitoring: Continue to monitor creatinine levels daily to catch any further decline in renal function promptly. This will help in making timely dosing adjustments and ensuring appropriate therapeutic levels of cefepime.
Consider Alternative Causes for Acute Kidney Injury (AKI): Evaluate for possible contributing factors to the patient’s renal decline, such as other nephrotoxic medications, dehydration, or infection-related kidney injury. Addressing reversible causes could help stabilize or improve renal function.
Evaluate for Signs of Cefepime Toxicity: Watch for symptoms of neurotoxicity, which is more likely in cases of renal impairment and cefepime accumulation (e.g., confusion, seizures, encephalopathy). Early recognition of these signs can prompt reevaluation of dosing or the need for an alternative antibiotic.
[Bedside Visit - Family plans patient transfer to Tri-Service General Hospital]
Today 2024-11-13, around 14:45, I visited the patient. His wife mentioned that, after discussion with the patient’s siblings, they intend to transfer him to Tri-Service General Hospital tomorrow.
I reminded her to continue monitoring his kidney function and hemoglobin levels after the transfer. She expressed that, as this is the first time someone in her family has been diagnosed with cancer, she has felt understandably anxious and overwhelmed. She conveyed her gratitude to the medical team and apologized if, in recent days, any unintended offense was caused.
[Bedside Visit]
I visited the patient on 2024-11-11 at approximately 11:50. The patient was in bed, with a newly hired caregiver by his side. The patient’s wife mentioned that after the abdominal drainage tube was removed last Friday (2024-11-08), ascites accumulated quickly, possibly also contributing to the low blood pressure observed on the following morning (Saturday, 2024-11-09). She questioned whether the tube may have been removed too early.
I informed her that I had observed the drop in blood pressure on Saturday morning and had contacted the nursing station to request a pause on the blood pressure medication. However, I advised that any concerns about the drainage tube should be discussed with the physician.
Regarding medication, I explained that waiting for the patient’s condition to stabilize before initiating chemotherapy is likely the most prudent approach.
It appears the patient’s wife still has unresolved questions regarding treatment and care, so it may be beneficial for team members in charge to reach out and address her concerns.
[Optimizing Care for AKI and Heart Failure] According to AKI diagnostic criteria, which typically involve a sudden increase in serum creatinine, this case meets the following criteria:
Given the rapidly accumulating ascites, managing the patient’s AKI and heart failure becomes more complex, especially regarding fluid management.
[Evaluation of the acitive medication list]
[Balancing Cancer Treatment and Cardiovascular Risk]
Pre-Existing Conditions and Cardiac History (Pre-2024)
Presentation with New Symptoms and Diagnosis of DLBCL (Mid-2024)
Treatment and Complications Post-Lymphoma Diagnosis (October 2024)
Challenges with Chemotherapy Planning:
[Managing Renal Impairment in a Patient with Lymphoma]
Given the patient’s recent laboratory data showing a notable increase in creatinine levels from 1.10 mg/dL on 2024-10-29 to 1.52 mg/dL on 2024-11-05, there are several considerations and recommendations:
Assessment and Potential Causes
Recommendations
[Navigating Treatment Challenges in Elderly Patients with DLBCL]
For this elderly patient with heart failure, renal impairment, and other comorbidities. Focus on balancing efficacy with potential toxicity, especially considering cardiac safety and tolerability. Possible regimens for DLBCL might be:
R-GCVP
R-CEOP
R-CDOP
R-mini-CHOP
R-CEPP
DA-R-EPOCH
Summary: For this case with renal impairment, heart failure, and advanced age, R-GCVP emerges as the most balanced regimen, followed by R-CEOP and R-CDOP. These regimens provide efficacy while minimizing renal and cardiac strain, with R-GCVP being the most favorable given its relatively lower toxicity profile.
Key Actionable Insights:
[Addressing Acute GI Bleeding and Anemia in this Vulnerable Patient]
Lab data
The recent laboratory findings indicate a concerning trend in hemoglobin levels, dropping from 12.0 g/dL on 2024-10-14 to 8.9 g/dL on 2024-11-05. This decline is accompanied by a positive fecal occult blood test (Stool OB: 4+), suggesting active gastrointestinal (GI) bleeding.
Comments and Clinical Insights
Suggested Actions and Management Plan
[Pharmacist’s Note: 2024-11-06 13:30 - Visit to Ward 12B]
During my visit to Ward 12B at approximately 13:30 today, I observed that the patient was awake, lying supine in bed, and appeared slightly weak. The primary caregiver is the patient’s wife, who also seemed somewhat fatigued from continuous caregiving responsibilities. She reported a recent lower back strain, which currently prevents her from bending down.
According to the patient’s wife, he has been experiencing frequent episodes of fever. She noted a recent downturn in his mood, likely due to disease developed, and prefers not to disclose detailed information about his condition to him to avoid increasing his anxiety. She also expressed a need for psychological counselling, as the sudden health changes have significantly impacted their family life and routine.
The couple has two daughters who studied abroad but are now working domestically. However, due to their busy work schedules, they have found it challenging to contribute consistently to his care.
In line with a holistic approach to care, I encouraged the family to view these changes positively and adapt as best as possible. I recommend that the healthcare team consider initiating a referral for psychological counselling to provide support for both the patient and his wife.
[lab data]
2024-08-07 Anti-HAV IgM Nonreactive
2024-08-07 Anti-HAV IgM Value 0.24 S/CO
2024-08-07 HBeAg Nonreactive
2024-08-07 HBeAg Value 0.365 S/CO
2024-08-07 HBsAg Nonreactive
2024-08-07 HBsAg Value 0.53 S/CO
2024-08-07 Anti-HBs >1000.00 mIU/mL
2024-08-07 Anti-HBc Reactive
2024-08-07 Anti-HBc Value 3.38 S/CO
2024-08-07 Anti-HCV Nonreactive
2024-08-07 Anti-HCV Value 0.05 S/CO
2024-08-07 Anti-HAV IgG Reactive
2024-08-07 Anti-HAV IgG Value 9.39 S/CO
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
Chemotherapy regimens for pancreatic cancer: Modified FOLFIRINOX - 2024-11-13 - https://www.uptodate.com/contents/image?imageKey=ONC%2F109546
Chemotherapy regimens for metastatic pancreatic cancer: FOLFIRINOX - 2024-11-13 - https://www.uptodate.com/contents/image?imageKey=ONC%2F79571
[Findings and Recommendations]
The patient presents a complex medical profile with multiple comorbidities and a recent diagnosis of moderately differentiated adenocarcinoma of the ampulla of Vater, managed surgically via a Whipple procedure on 2024-08-22.
Oncological and Surgical History
Medication Review and Recommendations - The current regimen includes medications for diabetes, hypertension, hyperlipidemia, and post-surgical nutritional support, among others. Key areas for attention:
Lab Results Analysis and Clinical Implications
Blood Glucose Management and Observations - The patient’s blood glucose readings post-chemotherapy and surgery show fluctuating but moderate control:
Recent Fasting Glucose: 127 mg/dL on 2024-10-30; glucose levels have ranged from 142 to 189 mg/dL as of 2024-11-13.
Recommendation:
Nutritional and Dietary Support - Considering the Whipple procedure and chemotherapy, nutritional support is critical to prevent further weight loss and support healing:
Imaging and Follow-up Recommendations
Chemotherapy Plan and Future Adjustments
[lab data]
2024-10-28 FLT3-D835 (BM) Undetectable
2024-10-16 NPM1 (quantative) (BM) Presence of mutation
2024-10-16 FLT3/ITD (BM) Undetectable
2024-10-08 Anti-HBc Nonreactive
2024-10-08 Anti-HBc Value 0.47 S/CO
2024-10-08 Anti-HBs 62.62 mIU/mL
2024-10-08 Anti-HCV Nonreactive
2024-10-08 Anti-HCV Value 0.11 S/CO
2024-10-08 HBsAg Nonreactive
2024-10-08 HBsAg Value 0.36 S/CO
2024-10-05 HBsAg Nonreactive
2024-10-05 HBsAg Value 0.25 S/CO
2024-10-05 Anti-HCV Nonreactive
2024-10-05 Anti-HCV Value 0.14 S/CO
[exam findings]
[MedRec]
[chemotherapy]
2024-11-13 - cytarabine 50mg ST SC 5min
2024-11-12 - cytarabine 50mg ST SC 5min
2024-11-11 - cytarabine 40mg ST SC 5min
2024-11-10 - cytarabine 40mg ST SC 5min
2024-11-09 - cytarabine 40mg ST SC 5min
2024-11-08 - cytarabine 40mg ST SC 5min
2024-11-07 - cytarabine 40mg ST SC 5min
2024-11-06 - cytarabine 40mg ST SC 5min
2024-11-05 - cytarabine 40mg ST SC 5min
2024-11-04 - cytarabine 20mg ST SC 5min
2024-11-01 - cytarabine 20mg ST SC 5min
2024-10-31 - cytarabine 20mg ST SC 5min
2024-10-30 - cytarabine 20mg ST SC 5min
2024-10-29 - cytarabine 20mg ST SC 5min
2024-10-28 - cytarabine 20mg ST SC 5min
2024-10-26 - cytarabine 20mg ST SC 5min
2024-10-25 - cytarabine 20mg ST SC 5min
2024-10-24 - cytarabine 20mg ST SC 5min
2024-10-23 - cytarabine 20mg ST SC 5min
2024-10-22 - cytarabine 20mg Q12H SC 5min
2024-10-21 - cytarabine 20mg Q12H SC 5min
2024-10-19 - cytarabine 20mg Q12H SC 5min
2024-10-18 - cytarabine 20mg Q12H SC 5min
2024-10-17 - cytarabine 20mg Q12H SC 5min
2024-10-16 - cytarabine 20mg Q12H SC 5min
2024-10-15 - cytarabine 20mg Q12H SC 5min (low dose Ara-C)
Acute myeloid leukaemia low dose cytarabine - 2024-10-24 - https://www.eviq.org.au/haematology-and-bmt/leukaemias/acute-myeloid-leukaemia/1182-low-dose-cytarabine
[Thrombocytopenia]
The patient’s recent lab results indicate persistent thrombocytopenia with platelet counts consistently below normal, dropping to critical levels in recent days:
Analysis of Thrombocytopenia in Context of AML and Cytarabine Therapy - Thrombocytopenia in this patient likely results from a combination of factors:
Risks Associated with Thrombocytopenia
Recommendations for Management
By implementing these recommendations, it may be possible to mitigate bleeding risks while continuing to manage the patient’s AML in a way that is tolerable and effective.
[examine the treatment timeline and subsequent blast count responses]
Timeline and Analysis of Cytarabine Doses and Blast Count
Observed Relationship Between Cytarabine and Blast Count
Interpretation and Clinical Insight
Recommendations
Prognosis
Medication Review and Suggestions
[FLT3/ITD undetectable: low-dose cytarabine replaces standard chemotherapy. Blast fluctuations: infection risk monitoring]
Lab results from 2024-10-16 show that FLT3/ITD (BM) is undetectable, so midostaurin or quizartinib are not indicated.
Due to the patient being considered unfit for intensive chemotherapy, low-dose cytarabine was started on 2024-10-15 instead of the standard 7+3 regimen.
On day 5, hypoplasia (blast <20%) was noted, and by day 7, blasts were reduced to <5%. However, the most recent data shows a rise to 12%.
The current 10-day session is ending soon, WBC might be expected to rise, but any fever or suspected infection should be promptly addressed due to the risk of prolonged neutropenia.
As for thrombocytopenia, platelet transfusion might be considered if clinically indicated.
2024-10-24 WBC 1.20 x10^3/uL
2024-10-23 WBC 0.98 x10^3/uL
2024-10-22 WBC 0.52 x10^3/uL
2024-10-21 WBC 0.43 x10^3/uL
2024-10-21 WBC 0.53 x10^3/uL
2024-10-20 WBC 0.40 x10^3/uL
2024-10-19 WBC 0.59 x10^3/uL
2024-10-18 WBC 0.63 x10^3/uL
2024-10-17 WBC 14.27 x10^3/uL
2024-10-16 WBC 53.32 x10^3/uL
2024-10-15 WBC 97.14 x10^3/uL
2024-10-24 Blast 12.1 %
2024-10-23 Blast 6.1 %
2024-10-22 Blast 5.6 %
2024-10-21 Blast 2.6 %
2024-10-21 Blast 11.7 %
2024-10-20 Blast 20.6 %
2024-10-19 Blast 16.7 %
2024-10-18 Blast 38.3 %
2024-10-17 Blast 85.9 %
2024-10-16 Blast 82.0 %
2024-10-15 Blast 85.0 %
2024-10-24 PLT 8 *10^3/uL
2024-10-23 PLT 15 *10^3/uL
2024-10-22 PLT 30 *10^3/uL
2024-10-21 PLT 35 *10^3/uL
2024-10-21 PLT 49 *10^3/uL
2024-10-20 PLT 48 *10^3/uL
2024-10-19 PLT 73 *10^3/uL
2024-10-18 PLT 106 *10^3/uL
2024-10-17 PLT 11 *10^3/uL
2024-10-16 PLT 21 *10^3/uL
2024-10-15 PLT 45 *10^3/uL
[AML likely: anemia, leukocytosis, and blasts at 73%]
Recent Lab Results
2024-10-07 Stool OB (LIA) Positive
2024-10-07 Occultblood (LIA) >999 ng/mL
2024-10-07 WBC 127.15 x10^3/uL
2024-10-07 HGB 9.0 g/dL
2024-10-07 PLT 25 *10^3/uL
2024-10-07 Blast 73.0 %
2024-10-07 Creatinine 3.17 mg/dL
2024-10-07 eGFR 15.01 ml/min/1.73m^2
2024-10-06 PT 13.4 sec
2024-10-06 APTT 37.0 sec
Based on the presence of 73% blasts in the peripheral blood, acute myeloid leukemia (AML) is a strong possibility. AML is characterized by the proliferation of abnormal myeloid precursor cells (blasts) in the bone marrow and peripheral blood, which disrupt normal hematopoiesis. Here’s why AML is likely in this case:
The prolonged PT and APTT and positive occult blood in stool may be related to thrombocytopenia.
Recommendations:
Bone Marrow Biopsy and Aspiration
Immunophenotyping by Flow Cytometry:
Cytogenetics and Molecular Testing:
[cardiac evaluation recommended prior to anthracycline therapy in AML]
If AML is confirmed and the standard cytarabine plus anthracycline (“7+3” therapy) is planned, it is recommended to perform a heart echo before chemotherapy to assess left ventricular ejection fraction (LVEF), as anthracyclines can affect heart function.
[lab data]
2020-08-29 PD-L1 (22C3) TPS >= 50%
2020-08-13 ROS1 not detected
2020-08-12 PD-L1 (22C3) TPS >= 50%
2020-08-07 ALK IHC Negative
2020-08-07 EGFR G719X not detected
2020-08-07 EGFR Exon19 del detected
2020-08-07 EGFR S768I not detected
2020-08-07 EGFR T790M not detected
2020-08-07 EGFR Exon20 ins not detected
2020-08-07 EGFR L858R not detected
2020-08-07 EGFR L861Q not detected
[exam findings]
2024-11-12 CT - abdomen
2024-11-12 KUB
2024-11-12 CXR
2024-11-12 ECG
2024-10-23 CXR
2024-10-08 Microsonography
2024-09-19 CT - chest
2024-08-07 Abdomen - Standing (Diaphragm)
2024-08-05 CXR
2024-08-05 Endoscopic Retrograde Cholangiopancreatography, ERCP
2024-08-02 CT - abdomen
2024-08-02 SONO - abdomen
2024-06-18, -05-13 CXR erect
2024-06-12 CT - chest
2024-05-09 2D transthoracic echocardiography
2024-04-23 Abdomen - supine (diaphragm)
2024-04-22 CXR erect
2024-04-22 Endoscopic Retrograde Cholangiopancreatography, ERCP
2024-04-19 PET
2024-04-15 Endoscopic Retrograde Cholangiopancreatography, ERCP
Duodenum
Papilla
Pancreatic duct
Common bile duct
Intrahepatic bile duct
Gallbladder
Others
2024-04-12 Patho - pancreas biopsy
2024-04-12 Endoscopic ultrasound, EUS
2024-04-09 Percutaneous Transhepatic Cholangio Drain, PTCD
2024-04-09 CT - abdomen
2024-04-08 CXR erect
2024-04-08 SONO - abdomen
2024-03-06 CT - chest
2023-11-24 CT - chest
2023-10-02 Tc-99m MDP bone scan
2023-08-31 CT - chest
2023-07-18 Tc-99m MDP bone scan
2023-06-09 CT - chest
2023-03-13 CT - chest
2022-10-24 CT - chest
2022-08-01 CT - chest
2022-04-12 CT - chest
2021-12-20 CT - chest
2021-08-15 CT - chest
2024-04-13 Tc-99m MDP bone scan
2021-04-13 CT - chest
2021-01-18 CXR erect
2020-12-09 CT - chest
2020-10-15 CT - chest
2020-07-27 Tc-99m MDP bone scan
2020-07-24 MRI - brain
2020-07-23 CXR
2020-07-23 Patho - lung transbronchial biopsy
2020-07-23 CT - chest
2020-07-22 Bronchodilator Test, BDT
2020-07-20 CXR erect
2020-07-20 SONO - chest
[MedRec]
[consultation]
[immunochemotherapy]
2024-10-23 - oxaliplatin 85mg/m2 50mg D5W 250mL 2hr + irinotecan 150mg/m2 90mg D5W 250mL 1.5hr + leucovorin 400mg/m2 240mg D5W 250mL 2hr + fluorouracil 2400mg/m2 1400mg D5W 500mL 46hr (FOLFIRINOX 50%)
2024-09-23 - oxaliplatin 85mg/m2 50mg D5W 250mL 2hr + irinotecan 150mg/m2 90mg D5W 250mL 1.5hr + leucovorin 400mg/m2 240mg D5W 250mL 2hr + fluorouracil 2400mg/m2 1400mg D5W 500mL 46hr (FOLFIRINOX 50%)
2024-08-22 - oxaliplatin 85mg/m2 70mg D5W 250mL 2hr + irinotecan 150mg/m2 130mg D5W 250mL 1.5hr + leucovorin 400mg/m2 340mg D5W 250mL 2hr + fluorouracil 2400mg/m2 2000mg D5W 500mL 46hr (FOLFIRINOX 70%)
2024-07-09 - oxaliplatin 85mg/m2 70mg D5W 250mL 2hr + irinotecan 150mg/m2 130mg D5W 250mL 1.5hr + leucovorin 400mg/m2 350mg D5W 250mL 2hr + fluorouracil 2400mg/m2 2100mg D5W 500mL 46hr (FOLFIRINOX 70%)
2024-06-19 - (FOLFIRINOX 70%)
2024-05-29 - (FOLFIRINOX 70%)
2024-05-13 - (FOLFIRINOX 70%)
2021-04-15 - ramucirumab 600mg NS 250mL 90min (Cyramza)
2020-12-09 - durvalumab 240mg NS 250mL 1hr (Imfinzi)
2020-12-08 - ramucirumab 600mg NS 250mL 90min (Cyramza)
2020-11-11 - ramucirumab 600mg NS 250mL 90min (Cyramza)
2020-10-15 - ramucirumab 600mg NS 250mL 90min (Cyramza)
2020-09-17 - ramucirumab 400mg NS 250mL 90min (Cyramza)
2020-08-19 - ramucirumab 400mg NS 250mL 90min (Cyramza)
2020-07-27 - ramucirumab 400mg NS 250mL 90min (Cyramza)
Tagrisso (osimertinib 80mg) - 2020-10-07 ~ undergoing Giotrif (afatinib 30mg) - 2020-08 ~ 2020-10
[tube feeding]
No oral drugs are currently documented on the active medication list.
[ChatGPT DoctorXMedical]
Key Findings
Medication Review and Recommendations
Monitoring and Follow-Up Recommendations
Additional Consultation
Palliative Care: Early palliative care involvement can be beneficial for symptom management, quality of life improvement, and anticipatory guidance in this context of metastatic malignancies.
GI Specialist: If GI bleeding persists, a gastroenterology consult may be warranted for further interventions, such as possible endoscopy.
Endocrinology: Given glucose variability, an endocrinologist’s input on glucose management might be beneficial if glycemic control remains challenging.
[no new WBC data since last pharmacist note]
Regarding the patient’s WBC count, there have been no new data since the 2024-09-24 pharmacist note. Please refer to the previous communication for the most recent details.
[managing neutropenia with G-CSF in reduced-dose FOLFIRINOX]
No neutropenia was observed on 2024-09-23 after starting Granocyte (lenograstim) on 2024-09-19.
Since 2024-05, the patient has not received the full dose of FOLFIRINOX, and on 2024-09-23, the dosage was even reduced to half of the standard dose. If neutropenia occurs in the future, further dose reduction is not recommended. Instead, using G-CSF to manage neutropenia is advised.
2024-09-23 WBC 12.89 x10^3/uL
2024-09-19 WBC 1.80 x10^3/uL
2024-08-22 WBC 4.41 x10^3/uL
2024-09-23 Neutrophil 88.1 %
2024-09-19 Neutrophil 36.0 %
2024-08-22 Neutrophil 65.4 %
[favorable tolerability of Tagrisso, effective FOLFIRINOX treatment with elevated CA199 levels]
A CT on 2024-08-02 showed stable disease under ongoing FOLFIRINOX treatment, suggesting the regimen remains effective. However, a CA199 level above 15,000 U/mL was observed on 2024-08-09, warranting further monitoring of disease progression.
Uliden (ursodeoxycholic acid) has been prescribed for elevated bilirubin. The patient has been taking Tagrisso (osimertinib 80mg) 1 tablet QD for lung cancer since 2020-10-07 and is tolerating the treatment well. No medication issues have been identified.
[addressing infection and bilirubin rise in patient care]
Lab results showed elevated PCT and CRP, suggesting a possible infection. The patient is being treated with Cravit (levofloxacin) and Mepem (meropenem). Additionally, bilirubin levels have rapidly increased, primarily due to elevated conjugated bilirubin. Uliden (ursodeoxycholic acid) has been administered. No medication issues have been identified.
2024-08-01 CRP 16.1 mg/dL
2024-08-01 Procalcitonin (PCT) 9.36 ng/mL
2024-08-02 Bilirubin total 3.72 mg/dL
2024-08-01 Bilirubin total 3.37 mg/dL
2024-07-09 Bilirubin total 0.95 mg/dL
2024-06-18 Bilirubin total 0.76 mg/dL
2024-06-07 Bilirubin total 0.47 mg/dL
2024-08-02 Bilirubin direct 2.64 mg/dL
2024-06-18 Bilirubin direct 0.28 mg/dL
2024-05-29 Bilirubin direct 0.11 mg/dL
[exam finding]
[No high-risk interactions between AKuriT-4 and micafungin]
Dr. Tien, Your phone inquiry has been answered as follows:
Currently, the patient is on AKuriT-4 (RIF rifampin 150mg, INH isoniazid 75mg, PZA pyrazinamide 400mg, EMB ethambutol 275mg) at 2.5 tablets QDAC. If micafungin is planned for use, UpToDate Drug Interactions indicates no interactions of Risk Level A or higher.
Key Problems Identified and Recommendations:
Mental Health Concerns: The patient has documented major depressive disorder and anxiety symptoms, including poor appetite, low self-esteem, and feelings of helplessness, noted on 2024-10-17 in both psychiatry and general medicine visits. This emotional distress could be exacerbating her physical symptoms. It is recommended to consult with an oncology psychologist.
[exam finding]
[MedRec]
[consultation]
[immunochemotherapy]
Patient Summary
Hematologic Status and Anemia Management
Cardiac and Renal Comorbidities
Chemotherapy and Oncology Considerations
Gastrointestinal and Nutritional Support
Medication and Symptom Management
[exam findings]
[surgical operation]
[chemotherapy]
Systemic Therapy for Endometrial Carcinoma - Endometrial Carcinoma - NCCN Clinical Practice Guidelines in Oncology - NCCN Evidence Blocks - Version 2.2023 - April 28, 2023 - ENDO-D
Primary or Adjuvant Therapy (Stage I-IV)
Recurrent Disease
Chronic Anemia
Hyperuricemia
Thrombocytopenia
Renal Function
Medication Review and Supportive Care
Anti-Ulcer Therapy: Ulstop FC (famotidine) appears on the active medication list, suggesting a proactive approach to gastrointestinal protection, especially important in the context of chemotherapy.
Hyperuricemia Management: Feburic (febuxostat) is appropriately prescribed for hyperuricemia, aligning with the elevated uric acid levels noted on 2024-11-11. Continuous use is advisable to manage tumor lysis syndrome risk associated with chemotherapy.
Potential for Additional GI Support: The presence of Actein (acetylcysteine) and Promeran (metoclopramide) suggests ongoing management of nausea and mucosal protection, these should be related to chemotherapy-induced side effects.
Recommendations:
Fluid and Electrolyte Management
Infection and Bleeding Risk
[continuing reduced-dose chemotherapy amid anemia and transfusions]
The patient has experienced anemia for at least six months, with a gradual decline in hemoglobin (HGB) levels. This coincides with the doxorubicin + cisplatin regimen that began in April, making it difficult to rule out the treatment as a cause of anemia. Despite the use of a reduced dose, the patient received blood transfusions on 2024-09-10 and 2024-10-11 and remains tolerant. The 2024-07-31 chest CT shows disease regression, so continuing with the reduced-dose treatment while the patient tolerates transfusions is recommended.
[exam finding]
[MedRec]
[chemotherapy]
[Grade 3 Mucositis and Stomatitis]
Oral Pain Management:
Additional Pain Management Support:
Oral Mucosal Healing:
Hydration and Nutritional Support:
[addressing severe neutropenia in TPF therapy: G-CSF interventions]
Leukopenia was noted on 2024-10-20, and the first session of the TPF regimen began on 2024-10-22.
By 2024-10-30, grade 4 neutropenia was observed, and G-CSF (filgrastim) was initiated on the same day, followed with Granocyte (lenograstim). WBC count recovery should be expected.
To help the patient continue with the standard TPF dosing despite neutropenia, prophylactive G-CSF administration could be considered in the future sessions, including long-acting options such as pegfilgrastim (including biosimilars).
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
Key Findings and Interpretation
Analysis of Potential Medication Issues
Recommendations:
[exam finding]
[MedRec]
[chemotherapy]
[Findings and Recommendations]
Nausea and Vomiting Management
Pain Management Concerns
Tranexamic Acid Use for Bleeding Control
Anemia and Possible Iron Deficiency
Electrolyte and Renal Function Monitoring
[lab data]
[exam finding]
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
[note: ChatGPT] - 2024-11-05
While the Neuroendocrine Tumors (NET) guideline could seem relevant given the neuroendocrine histology, the primary guideline to follow here is indeed Esophageal and Esophagogastric Junction Cancers because the NCCN categorizes cancer management based primarily on the site of origin rather than solely on the histologic subtype. Here’s a breakdown of why the esophageal guideline is more applicable in this case:
In conclusion, while the Neuroendocrine Tumors guideline applies broadly to neuroendocrine cancers, the Esophageal and Esophagogastric Junction Cancers guideline is more tailored to managing neuroendocrine carcinomas in the esophagus. For this patient, the Esophageal Cancer guideline is optimal due to the site-specific, histologic, and aggressive characteristics of the tumor.
[Management of Advanced Small Cell Neuroendocrine Carcinoma of the Esophagus]
Diagnosis and Initial Presentation:
Treatment Regimen and Adjustments:
Disease Monitoring:
Symptom Management:
A review of the patient’s medication history within HIS5 and PharmaCloud databases revealed no discrepancies.
[Recommendations]
Potential for Immunotherapy:
Chemotherapy Re-evaluation:
Supportive Care for Comorbidities:
Diagnosis and Initial Presentation:
Treatment Regimen Initiation and Adjustments:
Subsequent Treatment and Current Therapy:
Disease Stability and Monitoring:
Symptom Management and Supportive Care:
Lab Trends:
Insights and Recommendations
[exam finding]
[MedRec]
[consultation]
[surgical operation]
[Radiotherapy]
[chemotherapy]
[Management of Advanced Dedifferentiated Liposarcoma]
Diagnosis:
Treatment History:
Other Findings:
Follow-Up and Monitoring:
Systemic Therapy:
Surgical and Radiation Therapy Considerations:
Symptom Management and Supportive Care:
Hepatitis B Management:
A review of the patient’s medication history within HIS5 and PharmaCloud databases revealed no discrepancies.
[exam finding]
[MedRec]
[consultation]
[immunochemotherapy]
[exam findings]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
[addressing hypokalemia, hypomagnesemia, and hearing loss in endometrial cancer treatment]
This is a 60-year-old female with a recent diagnosis of high-grade endometrioid adenocarcinoma of the uterus, stage IIC (AJCC pT1b pN0, cM0, FIGO IIC). The patient underwent a total hysterectomy with bilateral salpingo-oophorectomy, lymph node dissection, and partial omentectomy. Post-surgery, she was started on chemoradiotherapy (CCRT) due to the aggressive histologic type and significant myometrial invasion.
Hypokalemia and hypomagnesemia were noted, and oral potassium and magnesium supplements (Const K and MgO tablets) are currently being given. No medication problems identified
[lab data]
[exam finding]
[MedRec]
Multidisciplinary Cancer Team Meeting Conclusion (2023-06-20):
Multidisciplinary Cancer Team Meeting Conclusion (2023-07-04):
[consultation] (not completed)
[surgical operation]
[radiotherapy]
[chemotherapy]
This 66-year-old woman has a complex medical history, primarily involving high-grade serous adenocarcinoma of the endometrium, aggressive in nature, and advanced in stage (2023 FIGO Stage IIIC1ii or Stage IVC if distant metastasis were present). She has undergone extensive treatment, including surgery, chemoradiotherapy, and additional supportive measures. Here’s a breakdown and some observations on her case:
Key Aspects Findings and Imaging:
Treatment Overview and Considerations:
Overall Observations and Recommendations:
No medication discrepancies were identified after reviewing HIS5 and PhamaCloud.
[exam findings]
[chemotherapy]
[MedRec]
[MultiTeam]
[comprehensive palliative approach for advanced pancreatic cancer care]
Patient Summary:
Urine and Serum Findings:
Medication Overview and Comments:
Recommendations for Medication Adjustments:
[lab data]
2024-10-28 HBsAg Nonreactive
2024-10-28 HBsAg Value 0.48 S/CO
2024-10-28 HBeAg Nonreactive
2024-10-28 HBeAg Value 0.337 S/CO
2024-10-28 Anti-HBc Reactive
2024-10-28 Anti-HBc Value 3.88 S/CO
2024-10-28 Anti-HCV Nonreactive
2024-10-28 Anti-HCV Value 0.08 S/CO
[exam findings] (not completed)
[MedRec]
[consultation]
2024-06-17 Hemato-Oncology
2024-03-11 Colorectal Surgery
2024-03-11 Hemato-Oncology
2022-09-06 Diagnostic Radiology
2022-06-09 Diagnostic Radiology
[exam findings]
[MedRec]
[chemotherapy]
[exam findings] (not completed)
[chemotherapy]
2024-10-23 - oxaliplatin 100mg/m2 170mg D5W 250mL 2hr (CapeOx)
2023-07-23 - oxaliplatin 85mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 450mg NS 250mL 2hr + fluorouracil 2800mg/m2 3200mg NS 1000mL 46hr
[exam findings] (not completed)
2024-10-09 CXR
2024-09-02 CXR
2024-08-27 Patho - pancreas total/subtotal resection
2024-08-22 Doppler color flow mapping
2024-08-21 PET
2024-08-20 PTCD (percutaneous transhepatic cholangio drainage)
2024-08-20 Patho - duodenum biopsy
2024-08-20 Flow volume chart
2024-08-19 Endoscopic Retrograde Cholangiopancreatography, ERCP
2024-08-16 CT - abdomen
2024-08-15 ECG
2024-08-01 Patho - colon biopsy
2024-07-31 Colonoscopy
2024-07-29 Pathology Level IV
2024-07-29 Pathology Level IV
2024-07-26 Esophagogastroduodenoscopy, EGD
2024-07-24 CXR
2024-07-24 ECG
2024-01-08 ECG
2000-05-19 SONO - nephrology
2019-12-26 Doppler color flow mapping
2017-01-05 ECG
[chemotherapy]
[exam findings]
[MedRec]
[chemotherapy]
[potassium supplementation and pain management in current treatment]
Lab results indicate hypokalemia, hypomagnesemia, and hyperuricemia.
Injectable KCl and oral Const-K are being used for potassium supplementation, and Feburic (febuxostat) is administered for hyperuricemia.
For pain management, the patient is on a fentanyl transdermal patch, Tramacet, and Neurontin. No medication issues have been identified.
[Tigecycline Dosage Adjustments for Renal and Hepatic Impairment]
Tigecycline Dosage Adjustments:
[lab data]
2024-07-23 HBsAg Nonreactive
2024-07-23 HBsAg Value 0.26 S/CO
2024-07-23 Anti-HBc Reactive
2024-07-23 Anti-HBc Value 1.63 S/CO
2024-07-23 Anti-HCV Nonreactive
2024-07-23 Anti-HCV Value 0.06 S/CO
[exam findings]
[MedRec]
[immunochemotherapy]
[neutropenia resolved post granocyte treatment]
Two doses of Granocyte (lenograstim) administered on 2024-09-18 and 2024-09-19 effectively resolved the neutropenia by 2024-09-20, and no further evidence of neutropenia has been observed since.
[adjusting Ulstop (famotidine) dose for declining kidney function]
The decline in eGFR suggests a potential deterioration in kidney function.
For patients with CrCl between 30 and 60 mL/minute, the dosing of Ulstop (famotidine) should be adjusted as follows:
[allergy]
[Family History]
[lab data]
[exam findings]
[MedRec]
[consultation]
[immunochemotherapy]
Topotecan - 2024-02-29 - https://www.uptodate.com/contents/topotecan-drug-information
[gemcitabine and paclitaxel showing initial success, but possible resistance emerging based on rising CA125]
The gemcitabine + paclitaxel regimen, initiated in late 2024-05, replaced the previous topotecan treatment. Initially, CA125 levels dropped from around 4000 U/mL in 2024-07 to a low of about 1300 U/mL, but have slowly risen again, exceeding 2000 U/mL by early 2024-10, suggesting the possibility of disease resistance..
Anemia was observed on 2024-10-12, and after an LPRBC transfusion, HGB improved from 8.2 to 9.7 g/dL. Liver and kidney function were acceptable, requiring no dosage adjustments.
Brosym (cefoperazone, sulbactam) is being used for elevated CRP, with no medication-related issues identified.
2024-10-12 CRP 13.1 mg/dL
2024-10-12 HGB 9.7 g/dL
2024-10-12 HGB 8.2 g/dL
2024-10-07 CA125 2079.3 U/mL
2024-08-12 CA125 1455.4 U/mL
2024-07-29 CA125 1364.1 U/mL
2024-07-02 CA125 1272.6 U/mL
2024-06-04 CA125 3963.4 U/mL
2024-05-13 CA125 2124.0 U/mL
2024-05-02 CA125 2517.9 U/mL
2024-04-23 CA125 1779.3 U/mL
2024-04-09 CA125 2451.5 U/mL
2024-04-02 CA125 1787.5 U/mL
Topotecan was initiated in late Feb 2024 following a CT scan on 2024-02-17 that showed progressing abdominal metastatic lymph nodes. This regimen will have been in use for three months by the end of this month. An updated imaging study may be arranged to evaluate the treatment effect, especially since the CA125 levels reached a record high on 2024-05-02.
Review of the patient’s medication regimen did not reveal any discrepancies
[irinotecan cycle 2: tolerated 1st session, labs clear]
The patient is admitted for the 2nd session of irinotecan therapy. This patient tolerated the 1st session well, and lab results from 2024-03-21, showed no contraindications for administration.
[disease progression after multiple regimens: Enhertu partial response & topotecan consideration]
The patient’s disease progressed after receiving paclitaxel and carboplatin, followed by liposomal doxorubicin and carboplatin. However, a partial response was observed with Enhertu (fam-trastuzumab deruxtecan-nxki. There was NO amplification of HER2 gene detected on 2023-07-26).
Enhertu is an antibody-drug conjugate (ADC) that delivers the topoisomerase I inhibitor payload deruxtecan (DXd). Topotecan, which is currently being used, is also a topoisomerase I inhibitor. Therefore, it is expected that there may still be a response, but with potentially higher adverse reactions.
Neutropenia was observed when Enhertu was previously administered, so close monitoring is recommended.
[chemotherapy]
2024-10-09 - azacitidine 75mg/m2 100mg SC D1-3 (Vidaza/Venetoclax)
2024-10-14 - Venclexta (venetoclax) - KVENC01
Venetoclax: Drug information - 2024-10-14 - https://www.uptodate.com/contents/venetoclax-drug-information
[neutropenia and thrombocytopenia likely from AML, not azacitidine and venetoclax]
The neutropenia and thrombocytopenia are likely caused by AML rather than the chemotherapy.
Vidaza (azacitidine) was started on 2024-10-09 and Venclexta (venetoclax) on 2024-10-14, both prescribed after the development of these conditions. Therefore, it’s unlikely that either drug caused them.
The blast percentage has been steadily declining since late September, sometimes falling below 20% (prior to chemotherapy) and recently down to 10%, suggesting that the treatment has shown initial positive results.
2024-10-13 WBC 0.54 x10^3/uL
2024-10-11 WBC 0.56 x10^3/uL
2024-10-10 WBC 0.42 x10^3/uL
2024-10-09 WBC 0.58 x10^3/uL
2024-10-08 WBC 0.51 x10^3/uL
2024-10-07 WBC 0.58 x10^3/uL
2024-10-05 WBC 0.60 x10^3/uL
2024-10-04 WBC 0.55 x10^3/uL
2024-10-03 WBC 0.90 x10^3/uL
2024-10-01 WBC 0.93 x10^3/uL
2024-09-30 WBC 1.79 x10^3/uL
2024-09-29 WBC 2.08 x10^3/uL
2024-09-28 WBC 3.25 x10^3/uL
2024-09-27 WBC 3.30 x10^3/uL
2024-09-26 WBC 6.20 x10^3/uL
2024-09-25 WBC 7.22 x10^3/uL
2024-09-25 WBC 8.65 x10^3/uL
2024-10-14 Neutrophil 0.5 %
2024-10-13 Neutrophil 5.0 %
2024-10-11 Neutrophil 4.9 %
2024-10-10 Neutrophil 1.5 %
2024-10-09 Neutrophil 2.2 %
2024-10-08 Neutrophil 1.9 %
2024-10-07 Neutrophil 5.2 %
2024-10-05 Neutrophil 6.2 %
2024-10-04 Neutrophil 4.1 %
2024-10-03 Neutrophil 3.9 %
2024-10-01 Neutrophil 7.7 %
2024-09-30 Neutrophil 5.9 %
2024-09-29 Neutrophil 1.0 %
2024-09-27 Neutrophil 5.7 %
2024-09-25 Neutrophil 2.0 %
2024-10-14 Blast 10.0 %
2024-10-13 Blast 10.8 %
2024-10-11 Blast 14.3 %
2024-10-10 Blast 16.9 %
2024-10-09 Blast 20.7 %
2024-10-08 Blast 12.5 %
2024-10-07 Blast 20.7 %
2024-10-05 Blast 27.2 %
2024-10-04 Blast 27.9 %
2024-10-03 Blast 26.9 %
2024-10-01 Blast 50.8 %
2024-09-30 Blast 54.2 %
2024-09-29 Blast 58.6 %
2024-09-27 Blast 79.0 %
2024-09-25 Blast 86.0 %
2024-10-14 PLT 4 *10^3/uL
2024-10-13 PLT 8 *10^3/uL
2024-10-11 PLT 7 *10^3/uL
2024-10-10 PLT 7 *10^3/uL
2024-10-09 PLT 6 *10^3/uL
2024-10-08 PLT 8 *10^3/uL
2024-10-07 PLT 5 *10^3/uL
2024-10-05 PLT 10 *10^3/uL
2024-10-04 PLT 15 *10^3/uL
2024-10-03 PLT 25 *10^3/uL
2024-10-01 PLT 7 *10^3/uL
2024-09-30 PLT 24 *10^3/uL
2024-09-29 PLT 27 *10^3/uL
2024-09-28 PLT 119 *10^3/uL
2024-09-27 PLT 3 *10^3/uL
2024-09-26 PLT 81 *10^3/uL
2024-09-25 PLT 16 *10^3/uL
2024-09-25 PLT 9 *10^3/uL
[Venclexta (venetoclax) in AML: stepwise dosing from today]
Venclexta (venetoclax) was first administered on 2024-10-14 following the recommended protocol for AML patients aged >= 75 or those with comorbidities.
The patient met the criterion of WBC <25,000/mm³ before starting venetoclax, so no further cytoreduction was necessary.
The dosing schedule:
[lab data]
2024-09-19 Anti-HBc Reactive
2024-09-19 Anti-HBc Value 5.16 S/CO
2024-09-19 Anti-HCV Reactive
2024-09-19 Anti-HCV Value 13.97 S/CO
2024-09-19 Anti-HBs 22.08 mIU/mL
2024-09-19 HBsAg Nonreactive
2024-09-19 HBsAg Value 0.33 S/CO
[exam findings]
[chemotherapy]
{Malignant neoplasm of body of penis}
[consultation]
[adjusting Cravit (levofloxacin) dose for patients with impaired renal function]
If the usual recommended dose of Cravit (levofloxacin) is 750 mg every 24 hours, for patients with CrCl < 20 mL/min, the initial dose should be 750 mg, followed by 500 mg every 48 hours.
The current regimen of 750 mg every other day should be reduced to 500 mg to better align with renal function.
2024-10-08 eGFR 12.24 ml/min/1.73m^2
2024-10-05 eGFR 6.35 ml/min/1.73m^2
2024-10-08 Creatinine 5.31 mg/dL
2024-10-05 Creatinine 9.38 mg/dL
[Crushing Const-K for Easier Administration - tube feeding]
Const-K 750mg is an extended-release potassium tablet containing 10 mEq of potassium per tablet. As the only oral potassium supplement available at this hospital, it can be crushed and administered with water for patients who cannot receive intravenous potassium supplementation.
[exam findings]
2024-09-25 CT - abdomen
2024-07-02 Myocardial perfusion SPECT with persantin
2024-06-13 PET
2024-06-13 2D transthoracic echocardiography
2024-06-12 Patho - bone marrow biopsy
2024-05-27 Merchant view - left knee
2024-05-27 Knee Lt standing
2024-05-13 Patho - lymphnode biopsy
2024-05-13 CXR
2024-05-13 Endoscopic Ultrasound, EUS
2024-04-16 CT - abdomen
2023-11-14 SONO - nephrology
2023-04-27 CT - abdomen
2022-09-14 CT - abdomen
2022-03-23 CT - abdomen
2021-09-30 CT - abdomen
2021-04-22 ENT Hearing Test
2021-03-04 CT - abdomen
2020-09-17 CT - abdomen
2020-07-01 PET
2020-06-24 CT - abdomen
2020-05-05 Patho - bone marrow biopsy
[MedRec]
[immunochemotherapy]
[exam findings]
2024-07-22 KUB
2024-07-22 CXR erect
2024-07-22 ECG
2024-07-17, -07-11 KUB
2024-07-17 CXR erect
2024-07-12 Tc-99m MDP bone scan
2024-07-04 EGD
2024-07-03 CT - abdomen
2024-07-03 ECG
2024-04-22 CT - abdomen
2024-03-28 Tc-99m MDP bone scan with SPECT
2024-01-18 CT - abdomen
2023-11-03 All-RAS + BRAF mutation
2023-10-04 CT - abdomen
2023-06-26 CT - abdomen
2023-06-26 CXR
2023-06-26 ECG
2023-05-31 CT - abdomen
2023-05-24 Peripheral Echography
2023-05-24 2D transthoracic echocardiography
2023-04-07, -02-23 CXR
2023-02-23 CT - abdomen
2023-01-27 Colonoscopy
2023-01-27 Esophagogastroduodenoscopy, EGD
2022-11-14 CT - abdomen
2022-10-12 Carotid angiography bilat. Vertebral angiography
2022-10-12 Aortography - thoracic
2022-10-11 ECG
2022-09-20 MRA - brain
2022-07-25 CT - chest
2022-06-27 2D transthoracic echocardiography
2022-06-21 CTA - chest
2022-06-21 Vein Sonography
2022-06-21 2D transthoracic echocardiography
2022-06-17 Patho - soft tissue tumor, extensive resection
……
2021-02-18 Patho - colon segmental resection for tumor
[consultation]
[surgical operation]
[chemotherapy]
[evaluating treatment resistance: 4-fold increase in tumor markers and disease progression]
Lab results showed a fourfold increase in both CEA and CA199 tumor markers in July. Early July CT scans revealed suspected mechanical colonic obstruction secondary to metallic stent occlusion, progressive liver and lung metastases, and enlarged metastatic nodes in the paratracheal and para-aortic spaces. These indicate that the disease has developed resistance to the Erbitux + FOLFIRI regimen. Next-line therapy might need to be considered.
2024-07-22 CEA (NM) 27.397 ng/ml
2024-07-02 CEA (NM) 7.355 ng/ml
2024-05-10 CEA (NM) 6.076 ng/ml
2024-04-17 CEA (NM) 4.699 ng/ml
2024-04-09 CEA (NM) 4.572 ng/ml
2024-03-22 CEA (NM) 4.149 ng/ml
2024-02-27 CEA (NM) 2.899 ng/ml
2024-07-22 CA-199 (NM) 25.661 U/ml
2024-07-02 CA-199 (NM) 6.732 U/ml
2024-05-10 CA-199 (NM) 7.109 U/ml
2024-04-17 CA-199 (NM) 6.103 U/ml
[propranolol dosage consideration following new BP data]
Lab data from 2024-01-29 and vital signs from the TPR panel appear largely within normal limits. However, the BP reading on the morning of 2024-01-30 was 98/51 mmHg, which is not considered high. Based on the clinical context, it might be feasible to slightly reduce the dosage of Propranolol (Propranolol) if deemed appropriate.
[leukopenia]
The temporal changes in the WBC count are summarized in the following table, where records marked with an asterisk represent WBC counts < 3K/uL.
The dosage of irinotecan used on 2023-06-20 was adjusted down from the standard 180mg/m2 to 160mg/m2.
On 2023-07-03, the ANC was 2.81K/uL x 41.9% = 1177/uL, which is a grade 2 neutropenia (1000~1499/uL). If this value occurs during a therapy cycle, a further decrease of 20mg/m2 to 140mg/m2 could be considered.
[exam findings]
[surgical operation]
[chemoimmunotherapy]
Rituximab (intravenous) including biosimilars - 2024-04-09 - https://www.uptodate.com/contents/rituximab-intravenous-including-biosimilars-drug-information
The patient was found to have mild microcytic anemia and hypomagnesemia.
MgSO4 is currently being administered, and iron supplementation might be added to address the anemia.
This patient has only visited our hospital in the past three months, mainly attending the hemato-oncology department, followed by the metabolism and endocrinology department. The former is for the treatment of follicular lymphoma, while the latter is for the management of type 2 diabetes mellitus.
The Uformin (metformin 500mg) 1# BID and Januvia (sitagliptin 100mg) 1# QD prescribed on 2023-05-12 by the metabolism and endocrinology department have been listed as patient-carried items in the active medication list. No medication reconciliation issues have been identified.
The last CT is dated on 2023-04-12, now in the beginning of July, a new CT scan could be considered to be arranged.
2023-01-10 lab data showed HGB 10.5g/dL, MCV 69.4fL, MCH 20.8pg, MCHC 30.0g/dL. These readings were all below their normal ranges.
Assessment based on the above lab items:
Recommendation:
[exam findings] (not completed)
[MedRec]
[surgical operation]
[chemotherapy]
2022-04-25
2022-04-15
2022-03-24
2022-03-17
2022-03-09
2022-03-01
2022-02-22
2022-01-24
2022-07-17
2022-01-10
2022-01-04
2021-12-27
2021-12-20
2021-11-29
2021-11-23
2021-11-15
2021-11-10
2021-11-01
2021-10-25
2021-09-27
2021-09-20
2021-09-13
2021-09-06
2021-08-30
2021-08-26
[switching Dulcolax to suppository form and crushing Kisqali for immediate tube feeding use]
For tube feeding considerations:
Dulcolax (bisacodyl) is enteric-coated, and crushing it could affect the upper digestive tract. It’s recommended to switch to a suppository form instead.
Kisqali FC (ribociclib) is film-coated, not enteric-coated, and does not cause staining when crushed. It’s advised to crush, dissolve, and administer it immediately to the patient. (source: Norvatis Ms Yang 0928-812-181. Tafinlar (dabrafenib) and Mekinist (trametinib) can also apply this method)
[exam findings] (not completed)
[MedRec]
[surgical operation]
[immunochemotherapy]
2024-09-12 - busulfan 32.mg/kg 218mg NS 300mL 3hr D1-3 + etoposide 400mg/m2 700mg NS 35mL 6hr D3-4 + cyclophosphamide 50mg/kg 3400mg NS 330mL 4hr D5-6 (BuCyE)
2024-07-02 - rituximab 375mg/m2 680mg NS 500mL 8hr D1 + methylprednisolone 500mg/m2 900mg NS 100mL 30min D2-5 + etoposide 40mg/m2 73mg NS 250mL 1hr D2-5 + cisplatin 25mg/m2 45mg NS 500mL 18hr D2-5 + cytarabine 2000mg/m2 3650mg NS 500mL 2hr D6 (R-ESHAP)
2024-06-03 - (R-GemOx)
2024-05-20 - (R-GemOx)
2024-04-29 - (R-GemOx)
2024-04-15 - (R-GemOx)
2024-04-01 - (R-GemOx)
2024-03-15 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + oxaliplatin 100mg/m2 185mg D5W 500mL 2hr D2 + gemcitabine 1000mg/m2 1800mg NS 100mL 30min D2 (R-GemOx)
2024-02-29 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + oxaliplatin 100mg/m2 185mg D5W 250mL 2hr D2 + gemcitabine 1000mg/m2 1800mg NS 100mL 30min D2 (R-GemOx)
2023-08-09 - Bacille Calmette-Guerin (BCG) 120mg ST BI 1hr
2023-08-02 - Bacille Calmette-Guerin (BCG) 120mg ST BI 1hr
2023-07-26 - Bacille Calmette-Guerin (BCG) 120mg ST BI 1hr
2023-07-19 - Bacille Calmette-Guerin (BCG) 120mg ST BI 1hr
2023-07-12 - Bacille Calmette-Guerin (BCG) 120mg ST BI 1hr
2023-07-05 - Bacille Calmette-Guerin (BCG) 120mg ST BI 1hr
2023-06-28 - mitomycin-C 30mg ST BI 1hr
2022-11-30 - mitomycin-C 30mg ST BI 1hr
2022-11-23 - mitomycin-C 30mg ST BI 1hr
2022-11-16 - mitomycin-C 30mg ST BI 1hr
2022-11-09 - mitomycin-C 30mg ST BI 1hr
2022-11-02 - mitomycin-C 30mg ST BI 1hr
2022-10-26 - mitomycin-C 30mg ST BI 1hr
2022-10-07 - mitomycin-C 30mg ST BI 1hr
2022-08-29 - rituximab 375mg/m2 684mg NS 500mL 6hr D1 + cyclophosphamide 750mg/m2 1300mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 60mg D5W 500mL 2hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 25mg PO QID D2-6 (R-CHOP)
2022-08-05 - (R-CHOP)
2022-07-07 - (R-CHOP)
2022-05-30 - (R-CHOP)
2022-05-03 - (R-CHOP)
2023-04-12 - (R-CHOP)
Intravesical Bacillus Calmette-Guerin - 2024-03-18 - https://www.uptodate.com/contents/intravesical-bacillus-calmette-guerin-drug-information
Mitomycin (intravenous and intravesical) (systemic) - 2024-03-18 - https://www.uptodate.com/contents/mitomycin-intravenous-and-intravesical-systemic-drug-information
[left-shifted WBC count sustained without G-CSF support]
Since 2024-10-01, after discontinuing G-CSF, the WBC count has decreased from its peak but remains within the lower end of the reference range. The WBC differential count shows a left shift, suggesting that white blood cells can likely sustain themselves following autologous blood stem cell transplant.
Blood glucose levels have stabilized around 200 ± 50 mg/dL, which is acceptable. Occasional tachycardia is noted, but TPR remains generally stable. No medication issues have been identified.
2024-10-04 Neutrophil 71.4 %
2024-10-04 Metamyelocyte 2.9 %
2024-10-04 Myelocyte 8.6 %
2024-10-04 WBC 3.93 x10^3/uL
2024-10-02 WBC 6.45 x10^3/uL
2024-10-01 WBC 8.78 x10^3/uL
[WBC rise and neutrophil normalization allow G-CSF discontinuation, continued hypokalemia requires potassium supplementation despite spironolactone]
On post-autoPBSCT day 8, the WBC showed a slight increase, and by day 10 and day 12, the rise became more pronounced, with neutrophil percentages falling within a normal range. As a result, G-CSF can be discontinued.
2024-10-01 WBC 8.78 x10^3/uL D12
2024-09-29 WBC 1.60 x10^3/uL D10
2024-09-27 WBC 0.16 x10^3/uL D 8
2024-09-25 WBC 0.02 x10^3/uL D 6
2024-10-01 Neutrophil 71.7 %
2024-09-29 Neutrophil 74.0 %
2024-09-27 Neutrophil 34.5 %
Additionally, ALT levels have notably increased to 2-3 times the upper limit of normal (ULN), and administering BaoGan (silymarin) is an appropriate action.
Persistent hypokalemia is likely due to increased cell production leading to more potassium entering cells, so potassium supplementation should be maintained despite using spironolactone.
[Urief recommended as alternative to Harnalidge in tube feeding]
Harnalidge OCAS (tamsulosin 0.4 mg) is not suitable for tube feeding due to its formulation. Therefore, it is recommended to switch to Urief (silodosin 8 mg) as a more appropriate alternative for managing the patient’s condition.
[day 7 post-autoPBSCT: managing pancytopenia and electrolyte imbalances]
Today marks Day 7 post auto-PBSCT, and the patient remains in the pancytopenia phase, receiving filgrastim 150 µg daily.
The patient has slightly elevated ALT, hypokalemia, hyponatremia, hypocalcemia, and hypoalbuminemia, with potassium and sodium already supplemented.
Blood glucose is around 200 mg/dL, which is acceptable, and renal function remains normal.
No dosage adjustments for liver or kidney function are currently necessary.
[diuresis and electrolyte control with spironolactone and furosemide]
Currently, the patient is using furosemide 20 mg IVD PRNQD and 0.298% KCl (K+ 20 mEq) in 0.9% NaCl 500 mL IVD QD to address hypokalemia and mild hyponatremia.
Co-administration of furosemide and spironolactone may be considered for conditions requiring fluid overload management, while helping to balance electrolytes, especially potassium. These drugs work synergistically to enhance diuresis and minimize electrolyte disturbances.
A common starting ratio is 50 mg spironolactone to 20 mg furosemide, adjustable based on response and lab results.
Autologous stem cell: D34+ 9.007/kg/(x 10^6), 2024/09/19 infusion from 10:09-10:25 (Stem Cell pre-weight 139g, Stem Cell post-weight 19.6g)
The patient’s AST and ALT levels over the past few months have fluctuated between 1x to 2x the normal range, while kidney function remains stable. The patient has comorbidities of hypertension, hyperlipidemia, and diabetes, along with a history of bladder cancer.
[lab data]
2024-10-04 Anti-HBc IgM Nonreactive
2024-10-04 Anti-HBc IgM Value 0.09 S/CO
2024-10-04 HBsAg Nonreactive
2024-10-04 HBsAg Value 0.38 S/CO
2024-10-04 HBeAg Nonreactive
2024-10-04 HBeAg Value 0.324 S/CO
2024-10-04 Anti-HCV Nonreactive
2024-10-04 Anti-HCV Value 0.14 S/CO
2024-10-04 Anti-HAV IgG Reactive
2024-10-04 Anti-HAV IgG Value 10.20 S/CO
2024-10-04 Anti-HAV IgM Nonreactive
2024-10-04 Anti-HAV IgM Value 0.16 S/CO
[MedRec]
[Comprehensive Management of Advanced Laryngeal Carcinoma]
The patient has an advanced laryngeal carcinoma with evidence of regional lymph node involvement and distant metastases to the liver. Laboratory findings corroborate hepatic dysfunction, likely secondary to metastatic disease. There is evidence of systemic inflammation, normocytic anemia, hyponatremia, and mild renal impairment.
Recommendations:
Foster Evohaler, Spiriva Respimat, metformin, Eltroxin (levothyroxine), Cravit (levofloxacin), and BaoGan (silymarin) are currently being used to address the patient’s underlying conditions and potential infections. No medication errors or inconsistencies were found.
[MedRec]
[immunochemotherapy]
[treating afatinib-related stomatitis with triamcinolone gel]
The patient is currently being treated with Giotrif (afatinib) and Avastin (bevacizumab). Since afatinib has a higher incidence of stomatitis (30-71%, with 9% being grade 3), compared to Avastin’s 2% incidence of oral mucosa ulcers, it is likely that afatinib is causing the symptoms.
As afatinib is the primary treatment, dose reduction is not recommended unless the side effects become intolerable. Instead, short-term use of Nincort Oral Gel (triamcinolone acetonide) can be considered for symptom relief.
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
2024-09-09 - bevacizumab 5mg/kg 200mg NS 100mL 1.5hr + B-Complex 1mL NS 250mL 45min
2024-08-26 - bevacizumab 5mg/kg 200mg NS 100mL 1.5hr + B-Complex 1mL NS 250mL 45min
2024-08-12 - bevacizumab 5mg/kg 200mg NS 100mL 1.5hr + B-Complex 1mL NS 250mL 45min
2024-07-29 - bevacizumab 5mg/kg 200mg NS 100mL 1.5hr + B-Complex 1mL NS 250mL 45min
2024-07-15 - bevacizumab 5mg/kg 200mg NS 100mL 1.5hr
2024-07-01 - bevacizumab 5mg/kg 200mg NS 100mL 1.5hr
2024-06-17 - bevacizumab 5mg/kg 200mg NS 100mL 1.5hr
2023-11-29 ~ undergoing - Xeloda (capecitabine 500mg) 1# BID
[PCT and CRP levels monitored under brosym treatment, rising CA199 and CEA levels with lung metastasis enlargement]
As of 2024-09-30, the patient’s PCT is 8.28 ng/mL and CRP is 28.7 mg/dL. The patient is currently being treated with Brosym (cefoperazole, sulbactam), and no medication issues have been identified.
Both CA199 and CEA levels showed an upward trend on 2024-09-23, and the 2024-08-26 CT scan indicated an enlarging metastasis in the right lower lung, this might be suggesting disease progression.
2024-09-23 CA199 136.36 U/mL
2024-09-09 CA199 47.64 U/mL
2024-08-26 CA199 53.05 U/mL
2024-08-12 CA199 83.31 U/mL
2024-07-29 CA199 64.29 U/mL
2024-07-01 CA199 46.01 U/mL
2024-06-18 CA199 47.08 U/mL
2024-09-23 CEA 8.08 ng/mL
2024-09-09 CEA 6.82 ng/mL
2024-08-26 CEA 9.18 ng/mL
2024-08-12 CEA 11.43 ng/mL
2024-07-29 CEA 14.25 ng/mL
2024-07-01 CEA 16.50 ng/mL
2024-06-18 CEA 28.10 ng/mL
2023-11-21 CEA 35.22 ng/mL
2023-10-07 CEA 33.63 ng/mL
2023-06-17 CEA 19.71 ng/mL
2022-11-08 CEA 12.31 ng/mL
2022-07-02 CEA 7.78 ng/mL
2021-12-18 CEA 4.79 ng/mL
2021-09-01 CEA 3.99 ng/mL
2021-04-28 CEA 5.10 ng/mL
2021-01-29 CEA 11.45 ng/mL
[exam findings]
[MedRec]
[chemotherapy]
[stable disease on CT, but rising CEA requires monitoring]
The 2024-09-25 CT scan comparison with the 2024-06-15 scan showed stable disease. However, CEA levels have shown a gradual increase over the past three months, which warrants further attention in future follow-ups. No medication issues have been identified at this time.
[monitoring slowed decline in CEA levels; liver metastases progression on current FOLFOX]
Lab data indicates that the CEA level continues to decline, however the rate of decrease has slowed, warranting further attention. Additionally, the 2024-06-15 CT scan showed progression of liver metastases. The current FOLFOX regimen remains unchanged, as liver and kidney functions are stable, and no dosage adjustments are necessary.
[FOLFOX treatment, decreasing CEA
]
The patient received FOLFOX chemotherapy on 2024-04-22, 2024-05-06 and 2024-05-29.
A noticeable decrease in CEA (carcinoembryonic antigen) levels has been observed. This could be an indication of the treatment’s effectiveness.
No inconsistencies were found in the patient’s medication list upon cross-referencing HIS5 and PharmaCloud databases.
[MedRec]
[surgical operation]
[immunochemotherapy]
[Grade 3 Anemia Treated with LPRBC Transfusion]
Anemia of grade 3 severity was confirmed by laboratory results. A transfusion of leukoreduced packed red blood cells (LPRBC) has been administered, and an increase in hemoglobin levels is anticipated.
[exam findings] (not completed)
[MedRec]
[no contraindication for chemotherapy with stable CKD and mild liver enzyme elevation]
Lab results from 2024-09-25 showed slightly elevated AST and ALT (about 1-2x ULN) and there was evidence of stage 2/3a CKD. Blood glucose is around 150 mg/dL (controlled with Galvus Met and Amepiride) and blood pressure is approximately 140/70 mmHg (managed with Concor, Hyzaar, and Coxine). Blood counts and electrolytes are within normal ranges, so there is no contraindication found for chemotherapy and no medication issues have been identified.
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
[no signs of neutropenia, elevated wbc raises infection concern]
There are currently no signs of neutropenia. On the contrary, the WBC count is higher than normal, which may indicate an infection.
[liver enzymes slightly elevated, function stable]
Lab results show the patient’s liver function has returned to stability, though enzyme levels remain slightly above the reference range. No medication issues were identified.
2024-09-06 ALT 42 U/L
2024-09-03 ALT 44 U/L
2024-09-01 ALT 51 U/L
2024-08-30 ALT 70 U/L
2024-08-23 ALT 55 U/L
2024-08-21 ALT 82 U/L
2024-08-14 ALT 103 U/L
2024-09-06 AST 42 U/L
2024-09-03 AST 46 U/L
2024-08-30 AST 43 U/L
2024-08-23 AST 38 U/L
2024-08-21 AST 75 U/L
2024-08-14 AST 68 U/L
[exam findings]
[MedRec]
[liver enzyme rise observed, no immediate adjustment needed]
Please note that the patient’s ALT and AST levels have shown a monotonic increase over the past two weeks. No liver dose adjustment is necessary at this time; however, close monitoring is required to ensure the trend does not continue or worsen.
2024-09-23 ALT 129 U/L
2024-09-16 ALT 45 U/L
2024-09-13 ALT 16 U/L
2024-09-23 AST 65 U/L
2024-09-16 AST 48 U/L
2024-09-11 AST 34 U/L
[adjusting Feburic dosage for mild hyperuricemia management considerations for renal impairment]
The patient was prescribed Feburic (febuxostat) at 80mg daily for mild hyperuricemia, recorded at 6.9 mg/dL on 2024-03-28. However, for patients with CrCl below 30 mL/minute, a lower dose of 40 mg once daily is generally recommended (package insert).
[to schedule therapeutic drug monitoring for Depakine]
Depakine (valproic acid) was started today, 2024-03-28, targeting a therapeutic trough range of 50 to 100 ug/mL for epilepsy management. While some patients may see improved seizure control at levels above 100 ug/mL, with an upper limit often set around 125 ug/mL by some experts, concentrations between 100 to 150 ug/mL may lead to toxicity. Seizure control might also be achieved at levels below the standard reference range.
Trough concentrations, typically measured just before the next dose for safety and efficacy, are recommended within 3 to 4 days post-initiation or dose adjustment. A trough level check could ideally be scheduled for 2024-04-01.
[cyclosporine-A TDM]
[Minutes of the Interprofessional Practice Meeting and Family Meeting]
[Interprofessional Practice Meeting and Family Meeting following up]
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
[medications suitable for tube feeding, shifting antiviral therapy based on renal function]
All medications on the active list are suitable for tube feeding.
Urine output from 2024-09-21 to 2024-09-23 was 2054, 1450, 490 mL, with serum creatinine rising from 2.97 to 4.28. Please ensure renal protection.
2024-09-24 Creatinine 4.28 mg/dL
2024-09-23 Creatinine 3.27 mg/dL
2024-09-22 Creatinine 2.97 mg/dL
2024-09-24 eGFR 14.62 ml/min/1.73m^2
2024-09-23 eGFR 19.95 ml/min/1.73m^2
2024-09-22 eGFR 22.29 ml/min/1.73m^2
Vemlidy (tenofovir alafenamide) is not recommended for patients with CrCl <15 mL/min, it is advisable to switch to Baraclude (entecavir) 1# Q3D for CrCl 10-30 mL/min.
The current Cefim (cefepime) 2g QD is appropriate for CrCl 11-29, and no dose adjustment is needed.
[managing hyperphosphatemia in this AKI patient]
According to KDIGO criteria, AKI is diagnosed by an increase in serum creatinine (sCr) of at least 0.3 mg/dL within 48 hours or by a 50% increase from baseline in 7 days. The patient’s sCr rose from 2.97 to 4.28 mg/dL between 2024-09-21 and 2024-09-23, confirming AKI.
Additionally, acute severe hyperphosphatemia (P = 8.6 mg/dL on 2024-09-24) with symptomatic hypocalcemia is life-threatening, and hemodialysis may be required if kidney function is impaired.
2024-09-24 P (Phosphorus) 8.6 mg/dL
2024-09-22 P (Phosphorus) 5.3 mg/dL
2024-09-24 Ca (Calcium) 2.18 mmol/L
2024-09-23 Ca (Calcium) 2.14 mmol/L
2024-09-22 Ca (Calcium) 2.04 mmol/L
2024-09-21 Ca (Calcium) 1.95 mmol/L
[Balancing Aspirin Use in Cardiovascular Patients with Thrombocytopenia]
The patient has chronic thrombocytopenia, with platelet counts ranging from 50 to 100 K/uL. Coagulation times, including PT and APTT, are at the upper end of the reference range.
The use of aspirin in a cardiovascular patient with a consistently low platelet count (thrombocytopenia) below 100,000 per microliter (K/μL) requires a careful assessment of the benefits and risks. Aspirin is a cornerstone therapy for preventing thrombotic events in cardiovascular disease due to its antiplatelet effects. However, in thrombocytopenic patients, the risk of bleeding is increased, and aspirin can further inhibit platelet function, potentially exacerbating this risk.
Key Considerations:
Recommendations:
Lab data:
2023-06-18 APTT 32.2 sec
2023-06-18 PT 12.0 sec
2023-06-18 INR 1.18
2024-09-22 PLT 63 *10^3/uL
2023-06-18 PLT 54 *10^3/uL
2023-01-01 PLT 64 *10^3/uL
2022-06-11 PLT 88 *10^3/uL
2022-03-27 PLT 90 *10^3/uL
2021-08-19 PLT 82 *10^3/uL
2021-01-22 PLT 110 *10^3/uL
2020-10-09 PLT 82 *10^3/uL
2020-09-13 PLT 76 *10^3/uL
[exam findings]
[MedRec]
[surgical operation]
[immunochemotherapy]
[MedRec]
[surgical operation]
[chemotherapy]
[Sepsis Ongoing but Stabilized Body Temperature Post Tapimycin]
Lab results suggest that sepsis is ongoing, although the patient’s body temperature has remained below 38°C since the afternoon of 2024-09-22. This occurred after starting Tapimycin (piperacillin 4g, tazobactam 0.5g) IVD Q6H on 2024-09-21. No medication issues have been identified thus far.
[MedRec]
[surgical operation]
[chemotherapy]
The patient expired at 06:55 on 2024/09/22.
[Administering Minirin Melt Tablet via Tube Feeding - The SSM Approach]
To primary nurse:
Minirin Melt (desmopressin 60mcg/tab) is a freeze-dried, orally disintegrating tablet. In cases where tube feeding is necessary, the Simple Suspension Method (SSM) can be used. This involves disintegrating the tablet in warm water to create a suspension for feeding tube administration without the need to crush the tablet or open capsules. This method ensures safe and effective medication delivery through the tube.
[exam findings]
[MedRec]
[immunochemotherapy]
[DLBCL with Mediastinal Involvement: Response to R-CHOP and Residual Disease]
The patient, diagnosed with Diffuse Large B-Cell Lymphoma (DLBCL) in the anterior mediastinum, has responded well to chemotherapy (R-CHOP), evidenced by the decrease in tumor size and improvement in hydrocephalus.
Imaging studies reveal residual disease in the mediastinum, with necrosis and moderate pleural effusion. The patient also exhibits tachycardia, anterior septal hypokinesia with preserved systolic function, and nonspecific T-wave abnormalities.
Although bone marrow biopsy is negative for malignancy, continued monitoring and treatment for DLBCL, alongside management of cardiovascular symptoms, is essential to improve outcomes.
No issues with medications have been identified.
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
[Stable Laboratory Values and Treatment Tolerance]
Lab results from 2024-09-18, including blood cell counts, electrolytes, and liver and renal function tests, were within normal limits. Recent vital signs were also stable. While the FOLFOX regimen omitted the 5-FU bolus have been administered multiple times, no adverse drug reactions have been observed to date.
[cleared for FOLFOX treatment: stable labs and vitals]
Lab results on 2024-08-28 were generally normal, and vital signs are stable, indicating no contraindications for the planned FOLFOX treatment. No medication issues were identified.
The patient underwent a PSA test as recommended by the urologist. The results were within normal limits. Additionally, no discrepancies were identified in the current medication regimen.
[bolus 5-fu omitted; oxaliplatin and diarrhea; microcytic anemia]
In the current treatment cycle started on 2024-04-11, the bolus dose of 5-FU was excluded from the dose-reduced infusional 5-FU in the FOLFOX regimen, with no records of bowel movements post-treatment available yet.
Both oxaliplatin and fluorouracil, components of FOLFOX, are associated with diarrhea, with oxaliplatin showing a 46% incidence rate for this side effect.
Persistent microcytic anemia has been noted with no sign of improvement.
If oral MgO supplementation fails to correct hypomagnesemia, intravenous MgSO4 could be considered as an alternative for magnesium supplementation.
2024-04-10 Mg (Magnesium) 1.6 mg/dL
2024-04-10 HGB 11.0 g/dL
2024-04-10 MCV 70.8 fL
[microcytic anemia - possible iron deficiency]
The patient had four bowel movements on 2024-03-18. Loperamide was added to his medication regimen to help manage this.
Lab findings are consistent with microcytic anemia. Iron supplementation may be beneficial to address this.
[exam findings]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
[Vemlidy Tube-Feeding Methods and G-CSF Prescribed for Neutropenia]
Vemlidy (tenofovir alafenamide) can be administered via feeding tube, either by splitting the tablet, crushing it, or using the simple suspension method (SSM).
Neutropenia was observed today, and a 3-day course of G-CSF (filgrastim) has been prescribed. No medication issues were identified.
2024-09-18 WBC 1.42 x10^3/uL
2024-09-18 WBC 1.57 x10^3/uL
2024-09-10 WBC 2.69 x10^3/uL
2024-09-02 WBC 3.93 x10^3/uL
2024-08-26 WBC 4.77 x10^3/uL
2024-08-19 WBC 7.59 x10^3/uL
2024-09-18 Neutrophil 58.9 %
2024-09-18 Neutrophil 56.1 %
2024-09-10 Neutrophil 75.8 %
2024-09-02 Neutrophil 72.5 %
2024-08-26 Neutrophil 79.1 %
2024-08-19 Neutrophil 80.3 %
[cisplatin and worsening renal function]
The patient’s serum creatinine levels have been steadily increasing over the past month. While the current cisplatin dose, administered as part of concurrent chemoradiotherapy, is not exceptionally high, however it is recommended to consider temporarily suspending cisplatin if there is evidence of a rapid decline in renal function.
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
[Optimizing Mesna Timing for Ifosfamide-Induced Hemorrhagic Cystitis Prevention]
Mesna for the prevention of ifosfamide-induced hemorrhagic cystitis:
For Holoxan (ifosfamide) 2600mg daily for 3 consecutive days, mesna should be given 3 times daily: each dose being 520mg (20% of 2600mg), totaling 1560mg daily. Based on prior hospitalization records (2024-08-20 to 2024-08-26), mesna was administered approximately at 09:00, 17:00, and 21:00, not perfectly aligning with the recommended 4-hour intervals. It is suggested to confirm correct mesna dosing times.
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
[Managing Ribociclib-Induced Leukopenia: Dosage Adjustment Guidelines]
Self-paid drugs Kisqali (ribociclib 200mg) 3# QD were initiated on 2024-07-29, followed by Femara (letrozole 2.5mg) 1# QD added on 2024-08-19.
Leukopenia was observed on 2024-09-15, which is less likely caused by the aromatase inhibitor letrozole and more likely related to ribociclib, as the incidence of leukopenia with ribociclib is reported at 27% to 33% (grade 3: 12% to 20%, grade 4: less than 1%, according to UpToDate).
2024-09-15 WBC 1.66 x10^3/uL
2024-08-19 WBC 3.00 x10^3/uL
2024-07-18 WBC 3.90 x10^3/uL
2024-07-11 WBC 2.86 x10^3/uL
2024-09-15 Neutrophil 38.4 %
2024-07-18 Neutrophil 50.7 %
2024-07-11 Neutrophil 51.9 %
For ribociclib-induced hematologic toxicity, the dosage adjustment recommendations are:
[exam findings] (not completed)
[chemotherapy]
[exam findings]
[MedRec]
[MultiTeam]
[monitoring GI bleed, pantoprazole adjustment, and ongoing bilirubin management]
Lab results from 2024-09-10 indicate positive occult blood (3+) in the nasogastric aspirate, suggesting acute upper gastrointestinal bleeding. The patient is not currently using NSAIDs, aspirin, or warfarin. Hydration support is being provided with NS 500mL every 12 hours and Bfluid 1000mL daily. Blood pressure dropped to around 95/50 on 2024-09-12 but is currently stable at 116/71, indicating no immediate need for large amount fluid resuscitation. HGB was 9.4 g/dL on 2024-09-02, and a repeat measurement may be necessary to determine if a blood transfusion is required.
The Panzolec Lyo (pantoprazole) package insert recommends dividing the daily dose into two administrations if it exceeds 80mg. Currently administered at 200mg once daily, the short half-life of pantoprazole in adults suggests that dividing the dose into at least twice daily could improve efficacy.
Based on the available data in HIS5, direct bilirubin levels are continuing to decline, although they remain above the reference range. Uliden (ursodeoxycholic acid) should be continued.
[family meeting outlines care plan prioritizing comfort and minimizing interventions]
On 2024-09-13 at 16:00, a family meeting was held in the 11A ward conference room, led by the attending physician, Dr. Xia. The patient’s family members in attendance included the patient’s daughter, son, and daughter-in-law.
During the meeting, Dr. Xia provided a detailed update on the patient’s recent condition, including recurrent gastrointestinal bleeding, infections, and changes in consciousness.
The family expressed that the children are in agreement regarding palliative care, with the only opposition coming from the patient’s husband, who has been receiving treatment for panic and anxiety at a clinic this year. After understanding the patient’s condition, the children emphasized their desire for their mother to experience as little pain as possible in the coming stages of care.
When discussing treatment options, the family agreed to forgo further antibiotics, endoscopies, and embolization procedures, but requested the continued use of pain relief, hemostatic agents, and nutritional supplements.
[improving bilirubin and albumin levels with ongoing hyponatremia]
Following the weekend, both hypoalbuminemia and elevated bilirubin have shown improvement. However, there has been no significant change in hyponatremia; continued sodium supplementation is recommended.
2024-08-26 Na (Sodium) 129 mmol/L
2024-08-22 Na (Sodium) 128 mmol/L
2024-08-26 Albumin (BCG) 2.5 g/dL
2024-08-22 Albumin (BCG) 1.9 g/dL
2024-08-26 Bilirubin total 7.19 mg/dL
2024-08-22 Bilirubin total 13.06 mg/dL
2024-08-19 Bilirubin total 19.65 mg/dL
2024-08-26 Bilirubin direct 4.26 mg/dL
2024-08-22 Bilirubin direct 7.91 mg/dL
2024-08-19 Bilirubin direct 11.05 mg/dL
[to adjust Panzolec administration frequency]
The Panzolec Lyo (pantoprazole) package insert states that if the daily dose exceeds 80mg, it should be divided into two doses per day. The current administration is 200mg once daily. It is recommended to consider administering the medication twice daily.
[medication review: QT prolongation and PPI duplication]
The patient is currently taking Emetrol (domperidone 10mg) 1 # PO TIDAC and Flucon (fluconazole) 200mg IVD QD.
Domperidone may enhance the QTc-prolonging effects of moderate risk QT-prolonging CYP3A4 inhibitors. Additionally, these inhibitors may increase the serum concentration of domperidone.
The product labeling for domperidone lists this combination as contraindicated. It is recommended to avoid using moderate risk QT-prolonging CYP3A4 inhibitors with domperidone.
Moderate risk QT-prolonging CYP3A4 inhibitors that may interact with domperidone include crizotinib, erythromycin (systemic), fluconazole, nilotinib, and ribociclib.
If this combination is necessary and unavoidable, close monitoring with ECG is required.
Additionally, the patient is also prescribed Pariet FC (rabeprazole 20mg) 1 # PO QDAC and Panzolec (pantoprazole) 200mg IVD QD. Since both medications are PPIs, please reconsider the need for using them together.
[considering BID dosing for pantoprazole due to short half-life]
Please recheck for any ongoing signs of gastrointestinal bleeding, such as occult blood in the stool.
The half-life elimination of pantoprazole in adults is relatively short at about 1 hour. Given this, the current once-daily dosing regimen could be reconsidered, and this high dose (current 200mg) might be divided into at least BID to optimize efficacy.
[monitoring fluid status in patients with liver issues]
Both hyperbilirubinemia and hypoalbuminemia are showing improvement, and Uliden (ursodeoxycholic acid) is being administered currently.
However, there is a lack of body weight and fluid input/output data on the TPR panel. It is advisable to obtain this data to monitor whether edema is developing or resolving, given the patient’s low albumin levels and the use of diuretics (furosemide 40mg QD, spironolactone 25mg BID).
2024-07-14 Bilirubin total 4.37 mg/dL
2024-07-02 Bilirubin total 6.82 mg/dL
2024-06-25 Bilirubin total 8.53 mg/dL
2024-06-20 Bilirubin total 11.20 mg/dL
2024-06-17 Bilirubin total 13.45 mg/dL
2024-06-13 Bilirubin total 23.72 mg/dL
2024-06-12 Bilirubin total 21.29 mg/dL
2024-06-11 Bilirubin total 25.05 mg/dL
2024-06-04 Bilirubin total 27.56 mg/dL
2024-07-02 Albumin (BCG) 3.0 g/dL
2024-06-25 Albumin (BCG) 2.9 g/dL
2024-06-20 Albumin (BCG) 2.3 g/dL
[exam findings]
[MedRec]
[bone marrow biopsy agreed after months of neutropenia and thrombocytopenia]
This 78-year-old male has had neutropenia and thrombocytopenia for several months (abdominal ultrasound performed on 2023-08-29 revealed splenomegaly). Previously, the patient and his family declined a bone marrow biopsy, but they recently agreed, and this admission is for the planned bone marrow examination.
Currently, his liver and kidney functions are stable. He has comorbidities including chronic respiratory failure post-tracheostomy and chronic obstructive pulmonary disease (COPD), both managed with medications from repeat prescriptions. No medication issues have been identified.
2024-09-11 WBC 2.29 x10^3/uL
2024-08-30 WBC 2.14 x10^3/uL
2024-08-02 WBC 2.51 x10^3/uL
2024-07-13 WBC 2.44 x10^3/uL
2024-07-01 WBC 2.26 x10^3/uL
2024-09-11 PLT 88 *10^3/uL
2024-08-30 PLT 76 *10^3/uL
2024-08-02 PLT 72 *10^3/uL
2024-07-13 PLT 79 *10^3/uL
2024-07-01 PLT 66 *10^3/uL
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[Compatibility of Cravit IV Solution for Infusion]
To primary nurse:
According to the package insert for “Cravit IV Solution for Infusion,” Cravit is compatible with the following solutions: - 0.9% Sodium Chloride Solution - 5% Glucose Injection - Ringer’s Solution with 2.5% Glucose - Parenteral nutrition (amino acids, glucose, electrolytes)
[large mediastinal tumor compressing heart]
A CT scan conducted on 2024-06-04 revealed the following findings:
A WBC differential count on 2024-06-06 showed a left-shifted distribution. Normal blood IgG, IgA, IgM levels were observed, along with elevated kappa and lambda free light chains and beta-2 microglobulin.
Lymphoma and/or mediastinal tumors are suspected. The pericardial effusion appears symptomatic; percutaneous pericardiocentesis might be considered. This approach, if feasible, could physically relieve the pressure on the heart more effectively than medication.
[exam findings] (not completed)
[MedRec]
[surgical operation]
[chemotherapy]
[Progression of Bone Metastases and Liver Function Concerns]
The patient began FOLFIRI in early 2023-09, followed by the addition of Avastin. In 2024-03, the regimen was changed to Avastin + FOLFOX. A bone scan in 2024-07, compared to the previous scan from 2023-09-05, revealed new bone lesions, suggesting progressive bone metastases. This progression is further supported by elevated tumor markers, with CEA around 10,000 ng/mL and CA199 over 20,000 U/mL.
Prolonged PT and APTT, elevated bilirubin and AST, and decreased albumin suggest worsening liver function. Phytonadione, Vemlidy (tenofovir alafenamide), and BaoGan (silymarin) have been administered, with no medication issues identified. If cholangitis is suspected, adding ursodiol (ursodeoxycholic acid) may be considered.
2024-09-11 PT 16.4 sec
2024-09-11 APTT 44.2 sec
2024-09-11 Bilirubin total 8.86 mg/dL
2024-09-11 Bilirubin direct 3.94 mg/dL
2024-09-11 AST 180 U/L
2024-09-11 Albumin (BCG) 2.8 g/dL
2024-09-10 CEA 9848 ng/ml
2024-09-06 CEA 9385 ng/ml
2024-08-27 CEA 7068.3 ng/ml
2024-07-30 CEA 2987.200 ng/ml
2024-07-12 CEA 1995.600 ng/ml
2024-06-28 CEA 2284.500 ng/ml
2024-06-20 CEA 1636.800 ng/ml
2024-05-30 CEA 954.340 ng/ml
2024-05-09 CEA 912.050 ng/ml
2024-04-26 CEA 1026.000 ng/ml
2024-04-19 CEA 444.940 ng/ml
2024-03-29 CEA 459.320 ng/ml
2024-03-12 CEA 427.290 ng/ml
2024-03-01 CEA 482.250 ng/ml
2024-02-23 CEA 253.140 ng/ml
2024-02-02 CEA 291.530 ng/ml
2024-01-19 CEA 363.960 ng/ml
2024-01-05 CEA 686.340 ng/ml
2023-12-22 CEA 771.7 ng/ml
2023-12-08 CEA 1273.3 ng/ml
2023-11-24 CEA 1881.500 ng/ml
2023-11-10 CEA 4289.000 ng/ml
2023-10-09 CEA 10571.00 ng/ml
2023-09-22 CEA 16656.00 ng/ml
2024-08-27 CA-199 23543.000 U/ml
2024-07-30 CA-199 6974.500 U/ml
2024-07-12 CA-199 10934.600 U/ml
2024-06-28 CA-199 9992.100 U/ml
2024-06-20 CA-199 5187.200 U/ml
2024-05-30 CA-199 2904.700 U/ml
2024-05-09 CA-199 3696.000 U/ml
2024-04-26 CA-199 3157.180 U/ml
2024-04-19 CA-199 1093.020 U/ml
2024-03-29 CA-199 1184.350 U/ml
2024-03-12 CA-199 1673.250 U/ml
2024-03-01 CA-199 1286.170 U/ml
2024-02-23 CA-199 580.240 U/ml
2024-02-02 CA-199 543.150 U/ml
2024-01-19 CA-199 788.400 U/ml
2024-01-05 CA-199 1174.500 U/ml
2023-12-22 CA-199 1699.1 U/ml
2023-12-08 CA-199 2352.800 U/ml
2023-11-24 CA-199 3859.000 U/ml
2023-11-10 CA-199 7413.200 U/ml
2023-10-09 CA-199 11271.60 U/ml
2023-09-22 CA-199 17653.00 U/ml
2023-08-22 CA-199 24117.50 U/ml
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
The patient passed away on 2024-09-09 at 13:24.
[managing septic shock and acute tubular necrosis in this neutropenic patient]
Sepsis-induced acute tubular necrosis is often linked to prerenal factors such as decreased kidney perfusion and systemic hypotension (89/55 recorded at 08:35 on 2024-09-09, with norepinephrine administered).
The patient meets KDIGO AKI criteria due to an increase in serum creatinine of ≥ 0.3 mg/dL within 48 hours or ≥ 50% within 7 days. Additionally, Procalcitonin (PCT) levels on 2024-09-09 are elevated at 19.82 ng/mL, indicating possible sepsis.
Neutropenia has also developed, and Granocyte (lenograstim) 250ug SC daily has been provided. Empiric antibiotic treatment with Targocid (teicoplanin) 400 mg Q12H and Mepem (meropenem) 1000 mg Q8H has been initiated for potential sepsis. No medication issues have been identified at this time.
2024-09-09 Creatinine 2.33 mg/dL
2024-09-06 Creatinine 1.02 mg/dL
2024-08-01 Creatinine 0.63 mg/dL
2024-07-29 Creatinine 0.60 mg/dL
2024-09-09 WBC 0.95 x10^3/uL
2024-09-06 WBC 9.39 x10^3/uL
2024-09-09 Neutrophil 16.7 %
2024-09-06 Neutrophil 70.4 %
[tube feeding]
All oral medications currently prescribed can be administered via a feeding tube.
Hypokalemia and hypomagnesemia have been managed with oral Const-K tablets and intravenous MgSO4 supplementation. No medication discrepancies have been identified.
[lab data]
2024-03-06 Anti-HBc Nonreactive
2024-03-06 Anti-HBc Value 0.19 S/CO
2024-03-06 Anti-HCV Nonreactive
2024-03-06 Anti-HCV Value 0.13 S/CO
2024-03-06 Anti-HBs 0.86 mIU/mL
2024-03-06 HBsAg Nonreactive
2024-03-06 HBsAg Value 0.25 S/CO
[exam findings]
2024-07-18 CT - abdomen
2024-04-17 Ultrasonography - gynecology
2024-03-30 MRI - pelvis
2024-03-27 Pure Tone Audiometry, PTA
2024-03-20 SONO - gynecology
2024-03-15 CT - abdomen
2024-03-15 SONO - gynecology
2024-03-11 Venous Duplex, peripheral echography
2024-03-08 Bronchodilator Test
2024-02-20 CT - chest
2024-02-16 2D transthoracic echocardiography
2024-02-02 PET scan
2024-01-11 Patho - ovary (tumor)
2024-01-10 Colonoscopy
2024-01-10 EGD
2023-12-18 CT - chest
2023-12-06 SONO - gynecology
2023-12-01 CT - abdomen
[MedRec]
[surgical operation]
[chemotherapy]
[Final Cycle of TP Regimen and Enlarged Lymph Nodes Investigation]
According to the treatment plan established in 2024-03, six cycles of the TP regimen should be scheduled, with doses administered on 2024-04-02, 2024-04-26, 2024-05-23, 2024-06-22, 2024-07-18, and 2024-09-07. This current admission marks the final, planned sixth cycle.
A CT scan from 2024-07 showed enlarged lymph nodes (up to 2.0 cm) in the bilateral inguinal regions and a nodule (9.5 mm) in the left lower lobe. Compared to the 2024-02 CT, the solitary lung nodule has not significantly grown. However, the enlarged inguinal lymph nodes were not observed in previous imaging, so even though CEA, CA125, and CA199 levels have remained stable over the past 2 to 3 months, further investigation into the cause of the inguinal lymph node enlargement is warranted.
Lab results from 2024-09-06 were generally normal, and no medication issues were identified.
[tocilizumab preparation and infusion for elderly COVID-19 patient]
Preparation and Administration of Actemra (tocilizumab) for COVID-19 Treatment
The patient, a 97-year-old male weighing 44 kg, is scheduled to receive Actemra (tocilizumab) for the treatment of COVID-19. Based on his diagnosis and weight, the recommended dose is 8 mg/kg ie 352mg. Since recent lab results show that his liver and renal functions are grossly normal, no dose adjustments are necessary for this treatment.
Preparation and Administration Instructions for IV Infusion:
Actemra for IV infusion must be prepared by a healthcare professional using aseptic techniques. Follow these steps for preparation:
Preparation Summary:
[lab data]
2024-05-29 Anti-HBc Reactive
2024-05-29 Anti-HBc Value 6.30 S/CO
2024-05-29 Anti-HBs 61.54 mIU/mL
2024-05-29 HBsAg Nonreactive
2024-05-29 HBsAg Value 0.41 S/CO
2024-05-29 Anti-HCV Nonreactive
2024-05-29 Anti-HCV Value 0.11 S/CO
2020-05-22 Urine Culture
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
[Stable Liver Function and Renal Considerations: fenofibrate contraindicated]
Liver function remains stable, and renal function has been consistent over the past three months, with serum creatinine fluctuating between 1.6 and 2.0 mg/dL. The current SCr is 1.72 mg/dL, and based on the patient’s weight (45kg) and age (74 years, female), the calculated creatinine clearance (CrCl) is 20 mL/min.
Lipanthyl Supra (Fenofibrate) is contraindicated in patients with a CrCl of <= 30 mL/min.
[renal dosing review and electrolyte supplementation]
eGFR is 33.25, and after reviewing the current active medications, no renal dose adjustment is necessary.
Hypomagnesemia and hypoalbuminemia were also noted; magnesium supplementation (MgSO4 injection) has been administered, and albumin supplementation may be considered.
[optimizing Xyzal dosage for this patient with reduced CrCl]
When levocetirizine is used in patients with CrCl between 10 and 30 mL/minute, it is recommended to use 2.5 mg twice weekly (every 3 or 4 days). Please adjust Xyzal (levocetirizine 5mg) to 0.5 tablets every 3 days at bedtime (0.5# Q3D HS).
[frequent transfusions; adjusting treatment for severe anemia]
The patient had grade 3 and grade 2 anemia before receiving initial chemotherapy at our hospital in mid-June this year (HGB 7.8 g/dL on 2024-06-13, 8.0 g/dL on 2024-05-02). Prior to gastric surgery, the patient was prescribed B-Red (hydroxocobalamin).
During FOLFOX treatment at our hospital, the doses were reduced (Oxa 65mg/m², 5FU 2000mg/m²). Recently, the patient developed severe anemia with HGB < 6.5 g/dL (6.2 g/dL on 2024-07-26 and 6.1 g/dL on 2024-06-28), occurring after the 1st session and before the 2nd session (2024-07-27). It cannot be ruled out that the anemia is not exacerbated by chemotherapy.
The patient received blood transfusions on 2024-04-29, 2024-05-03, 2024-05-07, 2024-05-13, 2024-06-13, 2024-06-21, 2024-06-28, and 2024-07-26. If the patient cannot tolerate frequent transfusions and severe anemia occurs after the 2nd session of chemotherapy, adjusting the regimen might be necessary.
A bleeding scan on 2024-07-02 did not definitively identify the source of the bleeding. It is possibly originating from the ascending colon or a more proximal area, such as the small intestine. This suspected bleeding site should be prioritized for treatment.
Furthermore, despite multiple transfusions, the patient’s MCV has decreased from nearly 100 fL at the beginning of 2024 to around 80 fL. Iron deficiency has been ruled out by adequate ferritin levels. However, the patient’s poor renal function (eGFR 24) affects erythropoiesis. It might be advisable considering the use of ESA might help the patient reach an HGB target of at least 8.5.
2024-07-26 eGFR 24.34 ml/min/1.73m^2
2024-07-08 eGFR 31.23 ml/min/1.73m^2
2024-06-30 eGFR 33.01 ml/min/1.73m^2
2024-07-01 Ferritin 208.2 ng/mL
2024-04-01 Ferritin 27.3 ng/mL
2022-03-07 Ferritin 72.1 ng/mL
2020-06-03 Ferritin 15.8 ng/mL
2024-07-26 MCV 81.4 fL
2024-07-08 MCV 85.3 fL
2024-07-02 MCV 85.0 fL
2024-07-01 MCV 85.6 fL
2024-06-30 MCV 83.4 fL
2024-06-28 MCV 88.7 fL
2024-06-24 MCV 87.9 fL
2024-06-21 MCV 87.3 fL
2024-06-17 MCV 87.9 fL
2024-06-13 MCV 91.1 fL
2024-05-28 MCV 92.1 fL
2024-05-22 MCV 89.2 fL
2024-05-22 MCV 91.1 fL
2024-05-20 MCV 89.8 fL
2024-05-16 MCV 91.0 fL
2024-05-13 MCV 90.2 fL
2024-05-11 MCV 90.4 fL
2024-05-10 MCV 90.7 fL
2024-05-09 MCV 92.4 fL
2024-05-08 MCV 91.5 fL
2024-05-07 MCV 90.9 fL
2024-05-06 MCV 89.0 fL
2024-05-04 MCV 90.7 fL
2024-05-02 MCV 96.0 fL
2024-04-29 MCV 97.6 fL
2024-04-25 MCV 97.7 fL
2024-04-01 MCV 98.5 fL
2024-01-08 MCV 97.5 fL
[tube-feeding considerations for Pariet and Pentop]
Most proton pump inhibitors (PPIs) are formulated with an enteric coating. This coating protects the medication from the acidic environment of the stomach, ensuring that it does not dissolve until it reaches the more neutral pH of the small intestine, allowing for proper absorption and effectiveness.
Pariet (rabeprazole) is available as enteric-coated tablets. It has been discontinued and replaced with injectable Panzolec (pantoprazole). If tube administration is still preferred, Takepron (lansoprazole) orally disintegrating tablets are a viable option.
Pentop (pentoxifylline) SR is designed as a sustained-release formulation due to its short half-life:
For tube-feeding, the sustained-release form needs to be broken down and administered in multiple doses to mimic the original sustained-release effect.
[h yponatremia & hyperkalemia: adrenal insufficiency might be suspected (Addison’s disease?)]
The patient has developed hyponatremia and hyperkalemia concurrently. It’s important to note that she is are not currently taking any diuretics.
2024-06-20 Na (Sodium) 127 mmol/L
2024-06-19 Na (Sodium) 126 mmol/L
2024-06-18 Na (Sodium) 128 mmol/L
2024-06-17 Na (Sodium) 129 mmol/L
2024-06-13 Na (Sodium) 139 mmol/L
2024-06-20 K (Potassium) 5.4 mmol/L
2024-06-19 K (Potassium) 5.7 mmol/L
2024-06-18 K (Potassium) 5.5 mmol/L
2024-06-17 K (Potassium) 5.7 mmol/L
2024-06-13 K (Potassium) 3.0 mmol/L
Glucocorticoid withdrawal unlikely: The single dose of betamethasone 4mg administered on 2024-06-14 as premedication for oxaliplatin is unlikely to cause glucocorticoid withdrawal symptoms.
Serum creatinine levels: While the serum creatinine has been ranging between 1.5 and 2.0 mg/dL recently, there haven’t been any signs of rapid worsening.
Possible cause: One potential explanation for this co-occurrence could be a mineralocorticoid deficiency.
Diagnostic suggestion: Testing cortisol and ACTH levels might be helpful in confirming this suspicion.
[unnecessary co-administration of 2 ARBs]
The following measures have been appropriately implemented:
However, the co-administration of two ARBs, Blopress (candesartan) and Diovan (valsartan), may not be necessary as they belong to the same therapeutic category and serve the same function.
[Anticoagulant Reversal with Beriplex P/N]
To nurse practitioner:
The available anticoagulant reversal agent for apixaban in this hospital is Beriplex P/N 500U/vial (containing Factors II, VII, IX, X, Protein C, and Protein S Antigen), used for treating and preventing bleeding during vitamin K antagonist treatment.
According to the drug’s package insert, the dose depends on the patient’s INR before treatment and the targeted INR. The following table provides approximate doses (ml/kg body weight of the reconstituted product and IU FIX/kg body weight) required to normalize the INR (e.g. ≤ 1.3) at different initial INR levels:
| Initial INR | 2.0 – 3.9 | 4.0 – 6.0 | > 6.0 |
|---|---|---|---|
| Dose (ml/kg) | 1 | 1.4 | 2 |
| Dose (IU FIX/kg) | 25 | 35 | 50 |
[exam findings]
[MedRec]
[chemotherapy]
[stable liver and kidney function with underlying acidosis concerns]
Liver function has remained stable in recent months, and kidney function, with serum creatinine around 1.5 mg/dL, shows no significant fluctuations. There are no active medications requiring dosage adjustments based on liver or kidney function. However, CRP is elevated at 16 mg/dL, and serum sodium is low at 124 mmol/L, both of which should be further investigated, with sodium supplementation as needed.
Blood Gas Analysis (2024-09-04):
The patient is on supplemental oxygen, it suggests a possible underlying metabolic acidosis with compensatory respiratory alkalosis. This could occur if metabolic acidosis, such as lactic acidosis, triggered hyperventilation as a compensatory mechanism. Despite oxygen therapy correcting the hypoxia, the metabolic acidosis might persist until its root cause is addressed. The blood gas results indicate this, with a mildly alkalotic pH, low PCO2, and slightly reduced bicarbonate levels, supporting the diagnosis of metabolic acidosis with compensatory respiratory alkalosis.
[renal dose for carboplatin, metoclopramide and cimetidine]
2023-07-04 Cre 1.56mg/dL, eGFR 46.6, weight 75.9kg => CrCl 45mL/min. The patient has kidney impairment, which might necessitate dose adjustments for some medications in the active list:
Please review the dosages and clinical conditions accordingly to ensure safe and effective therapy for the patient.
[exam findings] (not completed)
[consultation]
[surgical operation]
[chemotherapy]
[TS-1 - Instructions for Safe Handling and Administration of Suspended Medication - via Simple Suspension Method (SSM)]
Wearing Gloves and Mask: - It is recommended to wear gloves and a mask when suspending anticancer drugs. To minimize exposure to the preparer and the administrator, it is advisable to prepare the suspension inside a dispenser.
Suspending the Medication in Warm Water: - Remove the plunger from the dispenser and place the medication inside. Reinsert the plunger and draw 20 mL of 55°C warm water into the dispenser.
Allow the Medication to Dissolve: - Cap the dispenser and allow the medication to dissolve. Once the medication has disintegrated, visually confirm the suspension, then tilt the dispenser 90 degrees back and forth about 15 times to properly mix the suspension.
Administering the Medication: - Before administering the medication, flush the tube with warm water (about 37°C) to clear any residue, such as nutritional supplements, from the tube. Connect the dispenser to the tube and administer the suspension. Afterward, flush the tube again with warm water (about 37°C) to wash away any remaining medication.
How to Prepare Warm Water - Mix room temperature drinking water and boiling water in a 1:2 ratio to create warm water at approximately 55°C.
[exam findings]
[consultation]
BH:161.2 cm, BW: 62.5 kg
Diet: Vegetable Awakening Healthy Meal
Medication in OPD: Galvus met 1# BID, Acarbose 0.5# TIDAC, Tresiba 20u HS
Medication during hospitalization: novorapid 8U TIDAC, Tresiba 20u HS, Galvus met 1# BID
BUN/Crea(eGFR): 17/1.05/57
Na/K 139/4.1
ALT/AST/CRP:33/20/-
HbA1c:3/22 12.4%
The newly admitted patient’s F/S has not yet been documented.
4/22-5/16 AC 89-133, Lunch AC 111-127, Dinner AC 105-128, HS 99-153
Please keep Galvus met.
Please check finger sugar TIDAC+HS, and 3AM for three days.
If the patient shows signs of low blood sugar, like feeling dizzy, having a racing heart, shaking, sweating, or feeling hungry, please check her blood sugar.
Arrange META OPD follow up after discharge
[chemotherapy]
[stable tumor markers and disease control with satisfactory glucose levels]
Both tumor markers, CEA and CA199, have remained stable over the past four months, and CT and MRI scans from June showed that the disease is stable. Lab results from 2024-09-02 were generally acceptable, with blood glucose at 116 mg/dL at 18:10 on 2024-09-02, indicating satisfactory control. No medication issues were identified.
2024-09-02 CEA 8.04 ng/mL
2024-08-16 CEA 7.37 ng/mL
2024-07-29 CEA 9.54 ng/mL
2024-07-10 CEA 6.37 ng/mL
2024-06-28 CEA 7.13 ng/mL
2024-06-19 CEA 7.74 ng/mL
2024-06-01 CEA 6.87 ng/mL
2024-04-25 CEA 7.63 ng/mL
2024-09-02 CA199 349.04 U/mL
2024-08-16 CA199 342.65 U/mL
2024-07-29 CA199 429.57 U/mL
2024-07-10 CA199 302.20 U/mL
2024-06-28 CA199 325.25 U/mL
2024-06-19 CA199 307.76 U/mL
2024-06-01 CA199 320.48 U/mL
2024-04-25 CA199 446.25 U/mL
[bedside visit - patient education and care in chemotherapy initiation]
As the patient is undergoing chemotherapy for the first time today, I visited them around 16:15 on 2024-03-27 to inquire if anyone had explained the potential side effects of chemotherapy to her. The patient confirmed that both her doctor and nursing staff had provided an explanation.
The patient lives nearby, and her uncle on her mother’s side is a monk, which is why they chose to receive medical treatment at out hospital. I advised the patient to inform the medical staff as soon as possible if they suspect any adverse reactions to medications, to allow for prompt management.
[exam findings] (not completed)
[chemotherapy]
[Morphine and Tramacet Dosage Guidelines for Patients with Liver Impairment]
Morphine Dosage Adjustments for Patients with Liver Impairment:
Tramacet (tramadol, acetaminophen) for adults with liver impairment: - Use is not recommended due to extensive hepatic metabolism of both acetaminophen and tramadol.
[lab data]
2024-03-01 HBsAg Nonreactive
2024-03-01 HBsAg Value 0.39 S/CO
2024-03-01 Anti-HBs >1000.00 mIU/mL
2024-03-01 Anti-HBc Reactive
2024-03-01 Anti-HBc Value 5.37 S/CO
2024-03-01 Anti-HCV Nonreactive
2024-03-01 Anti-HCV Value 0.08 S/CO
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
[regular monitoring recommended for elevated glucose levels]
In recent months, serum glucose levels have remained stable at approximately 140 mg/dL, which is slightly elevated but relatively consistent. The patient is currently taking Uformin (metformin) and Pravafen (pravastatin, fenofibrate) as prescribed by the endocrinology and metabolism department. Regular follow-up is recommended.
[assessing FOLFOX treatment with no contraindications, normal lab results and continuation of Vemlidy]
Lab results on 2024-08-13 were generally normal, and Vemlidy (tenofovir alafenamide) has been prescribed for her reactive Anti-HBc (2024-03-01). There is currently no data indicating that FOLFOX treatment is contraindicated. No issues with the current medication regimen were identified.
[exam findings]
[chemotherapy]
[neutropenia recovery and worsening anemia after etoposide]
The third dose of etoposide was administered on 2024-08-29. Neutropenia improved, with ANC increasing from 1.16K/uL on 2024-08-28 to 2.25K/uL on 2024-08-30. However, despite elevated ferritin levels, normocytic anemia worsened (HGB dropped from 9.1 g/dL to 8.4 g/dL), leading to a blood transfusion on 2024-08-30. HGB is expected to improve following the transfusion.
2024-08-30 WBC 2.75 x10^3/uL
2024-08-30 Neutrophil 78.0 %
2024-08-30 Band 4.0 %
2024-08-28 WBC 2.21 x10^3/uL
2024-08-28 Band 1.0 %
2024-08-28 Neutrophil 51.6 %
2024-08-30 HGB 8.4 g/dL
2024-08-30 MCV 93.1 fL
2024-08-28 HGB 9.1 g/dL
2024-08-28 MCV 91.7 fL
2024-08-28 Ferritin; 989.1 ng/mL
2024-08-28 Procalcitonin (PCT) 0.07 ng/mL
[liver enzymes decline, indicating improved liver function]
Follow-up shows that the elevated liver enzymes have started to decline, and bilirubin levels remain within the normal range, indicating an improvement in liver function.
2024-08-28 ALT 114 U/L
2024-08-26 ALT 167 U/L
2024-08-28 AST 25 U/L
2024-08-23 AST 44 U/L
[dose adjustments and liver safety for rifampicin, clarithromycin, and ethambutol]
Liver Dose Adjustments:
Hepatotoxicity:
Among these three medications, rifampin appears like to have a higher likelihood of causing liver damage. The patient’s ALT levels are currently trending upward.
The rifampin package insert indicates that caution should be exercised when administering this drug to patients with alcoholism or hepatic impairment. It is recommended that SGOT and SGPT levels be monitored monthly or more frequently before, during, and throughout treatment. However, elevated serum levels do not necessarily predict clinical hepatitis, and they may return to normal with continued treatment.
2024-08-26 ALT 167 U/L
2024-08-23 ALT 154 U/L
2024-08-16 ALT 110 U/L
2024-08-12 ALT 64 U/L
2024-08-02 ALT 30 U/L
2024-08-23 AST 44 U/L
2024-08-16 AST 30 U/L
2024-08-12 AST 24 U/L
2024-08-02 AST 15 U/L
[blood count trends and chemotherapy effects]
Etoposide was administered on 2024-08-08. Since then, WBC has slightly decreased, while PLT has actually increased. A review of the patient’s previous records, prior to the use of etoposide, shows that WBC and PLT levels were even lower at times. Therefore, the neutropenia and thrombocytopenia observed cannot be entirely attributed to chemotherapy alone.
2024-08-12 WBC 1.45 x10^3/uL
2024-08-10 WBC 1.75 x10^3/uL
2024-08-08 WBC 1.57 x10^3/uL
2024-08-05 WBC 1.69 x10^3/uL
2024-08-12 PLT 53 *10^3/uL
2024-08-10 PLT 52 *10^3/uL
2024-08-08 PLT 42 *10^3/uL
2024-08-05 PLT 41 *10^3/uL
[exam findings]
[chemotherapy]
[lab data]
2024-08-05 Anti-HBc Reactive
2024-08-05 Anti-HBc Value 5.42 S/CO
2024-08-05 HBsAg Nonreactive
2024-08-05 HBsAg Value 0.77 S/CO
2024-08-05 Anti-HCV Nonreactive
2024-08-05 Anti-HCV Value 0.12 S/CO
[exam findings]
[chemotherapy]
[using Avastin and FOLFIRI in patients with RBBB and LAFB: risks and monitoring]
Avastin (bevacizumab) in combination with FOLFIRI is not specifically contraindicated in patients with ECG (2024-08-12, 2024-08-29) findings such as right bundle branch block (RBBB) and left anterior fascicular block (LAFB). However, using this combination therapy should be approached with caution, particularly considering the patient’s cardiovascular status.
Considerations:
[first session of FOLFIRI with adjusted dosage and ongoing management]
The first session of FOLFIRI started on 2024-08-12, with 80% of the standard dose administered. Hypomagnesemia (Mg 1.5 mg/dL on 2024-08-12) and reactive Anti-HBc (Anti-HBc value 5.42 S/CO on 2024-08-05) were noted, so the patient is currently receiving injectable MgSO4 and oral Vemlidy (tenofovir alafenamide).
Blood pressure was 144/65 mmHg at 20:34 on 2024-08-12 under Estengy (amlodipine, valsartan) and blood glucose was 158 mg/dL at 06:54 on 2024-08-13 under Uformin (metformin) and Amepiride (glimepiride). Both blood pressure and blood glucose are under control. No medication discrepancies were identified.
[exam findings]
[MedRec]
[chemotherapy]
[iron supplementation recommended for microcytic anemia management]
Neutropenia (ANC = 2.35K/uL) and microcytic anemia were noted, while other lab results on 2024-08-28, including electrolytes, liver, and renal functions, were generally normal.
The most common cause of acquired microcytic anemia is iron deficiency. Lab results on 2024-05-27 showed decreased transferrin and relatively low ferritin levels, indicating that iron supplementation is recommended.
2024-08-28 WBC 3.48 x10^3/uL
2024-08-28 Neutrophil 67.8 %
2024-08-28 HGB 9.7 g/dL
2024-08-28 MCV 71.9 fL
2024-05-27 Ferritin 110.1 ng/mL
2024-05-27 Transferrin 195.5 mg/dL
2024-05-27 Fe (Iron-bound) 100 ug/dL
[microcytic anemia and potential cisplatin involvement]
The 50% dose reduction of cisplatin in the PF regimen has not prevented the HGB levels from decreasing, and the microcytic anemia continues to gradually worsen. The involvement of cisplatin in this condition cannot be ruled out.
The patient is also taking Giotrif (afatinib) 30mg QOD. However, the incidence of anemia with this drug has not been reported (UpToDate), making it less likely to be associated with the anemia.
2024-06-29 HGB 10.8 g/dL
2024-06-14 HGB 11.3 g/dL
2024-05-31 HGB 12.5 g/dL
2024-05-27 HGB 8.8 g/dL blood transfusion on 5/27
2024-05-22 HGB 7.9 g/dL blood transfusion on 5/23
2024-06-29 MCV 71.8 fL
2024-06-14 MCV 71.1 fL
2024-05-31 MCV 71.3 fL
[Reduced-Dose PF3 Regimen and Microcytic Anemia Management - Iron Deficiency Likely, Testing Recommended]
A reduced-dose PF3 chemotherapy regimen was initiated on 2024-04-20, with the second session commencing on 2024-05-22.
Notably, the patient’s anemia pre-dated the start of chemotherapy. Therefore, chemotherapy cannot be definitively identified as the sole cause of the anemia.
However, it is important to acknowledge that the anemia worsened after initiating the reduced-dose regimen. While the lower dose may have mitigated some effects, the chemotherapy might still be contributing to the severity of the anemia.
To address the anemia, leukocyte-poor red blood cell (LPRBC) transfusions were administered. This is considered an appropriate intervention.
The anemia has been identified as microcytic, a type of anemia commonly associated with iron deficiency.
To determine if iron supplementation is necessary, testing iron stores is recommended.
2024-05-22 HGB 7.9 g/dL
2024-05-13 HGB 9.8 g/dL
2024-05-06 HGB 9.6 g/dL
2024-04-23 HGB 9.6 g/dL
2024-04-19 HGB 9.0 g/dL
2024-04-08 HGB 10.0 g/dL
2024-04-01 HGB 10.0 g/dL
2022-11-10 HGB 11.0 g/dL
2024-05-22 MCV 68.5 fL
2024-05-13 MCV 68.8 fL
2024-05-06 MCV 68.8 fL
2024-04-23 MCV 67.3 fL
2024-04-22 MCV 68.8 fL
2024-04-19 MCV 66.1 fL
2024-04-08 MCV 67.7 fL
2024-04-01 MCV 68.3 fL
2022-11-10 MCV 68.3 fL
[lab data]
[exam findings]
[MedRec]
[radiotherapy]
[chemotherapy]
[Post-Transfusion Hemoglobin Level to be Monitored]
Normocytic anemia was observed on 2024-08-22 (HGB 7.9 g/dL), and a LPRBC transfusion was administered on the same day. The patient received FOLFOX chemotherapy on 2024-07-16, 2024-08-05, and 2024-08-26.
Previous records indicate a low hemoglobin level of 7.3 g/dL on 2024-06-10. The possibility that FOLFOX chemotherapy contributed to the anemia cannot be ruled out.
Given the recent blood transfusion, the hemoglobin level is expected to have increased. A repeat CBC is recommended to confirm this.
2024-08-22 HGB 7.9 g/dL
2024-08-13 HGB 9.1 g/dL
2024-08-05 HGB 9.4 g/dL
2024-07-30 HGB 9.8 g/dL
2024-07-15 HGB 8.9 g/dL
2024-08-22 MCV 91.4 fL
2024-08-13 MCV 86.3 fL
2024-08-05 MCV 88.2 fL
2024-07-30 MCV 87.9 fL
2024-07-15 MCV 83.7 fL
[anemia management, stable vital signs, and controlled blood glucose]
Lab results on 2024-08-22 indicated anemia and a left-shifted WBC count. LPRBC transfusion was performed the same day. Other lab results were unremarkable, and vital signs remain stable. Blood glucose levels are slightly above 100 mg/dL and are under control. No medication issues were identified.
2024-08-22 WBC 7.67 x10^3/uL
2024-08-22 HGB 7.9 g/dL
2024-08-22 Band 3.8 %
2024-08-22 Neutrophil 67.6 %
2024-08-22 Lymphocyte 3.8 %
2024-08-22 Monocyte 10.5 %
2024-08-22 Eosinophil 1.9 %
2024-08-22 Basophil 0.0 %
2024-08-22 Metamyelocyte 3.8 %
2024-08-22 Myelocyte 7.6 %
2024-08-22 Promyelocyte 1.0 %
2024-08-22 Atypical Lymphocyte 0.0 %
[AKI detected, diclofenac switch considered; hold chemotherapy for AKI resolution]
On 2024-05-21, the patient’s serum creatinine (SCr) level rose significantly, meeting the criteria for AKI as defined by the KDIGO guidelines.
Due to this AKI, switching the current medication Meitifen (diclofenac) to Tramacet (tramadol, acetaminophen) might be a suitable course of action.
Chemotherapy administration should be postponed until the AKI has resolved to minimize any further risk to kidney function.
[exam findings]
[MedRec]
[chemotherapy]
[lab data]
2024-08-24 G-6-P-D 0.2 U/gHb
[exam findings]
[recommendations for managing G6PD deficiency with current medications]
The nurse practitioner informed me this morning that the patient has G6PD deficiency.
The following medications are likely to be UNSAFE in moderate to severe G6PD deficiency, as cited from UpToDate (https://www.uptodate.com/contents/image?imageKey=HEME%2F74254):
The active medication list has been reviewed. Amamet contains both metformin and glimepiride, the latter being a sulfonylurea. If G6PD deficiency is confirmed (2024-08-24 G6P 0.2 U/gHb, ref: 6.4 ~ 12.9 U/gHb), it is recommended to temporarily discontinue this medication.
[combination therapy for BPH: doxazosin and dutasteride]
It has been noted that the patient also has BPH. Since Doxaben XL (doxazosin 4mg/tab) 1# HS is currently being used, if clinical results remain unsatisfactory, two options can be considered:
These medications can be used together as combination therapy to manage BPH, effectively reducing symptoms, improving urinary flow, and potentially slowing disease progression.
Considerations of the combination therapy: doxazosin, an alpha-1 blocker, can cause blood pressure reduction, especially with the first dose. This effect may be more pronounced when combined with dutasteride, particularly in patients on antihypertensive therapy, so careful monitoring of blood pressure is essential when starting this combination. Additionally, the risk of orthostatic hypotension may increase, so patients should be advised to rise slowly from sitting or lying down to avoid dizziness or fainting. Extra caution is required if the patient’s liver function is deteriorating, as both medications are metabolized by the liver.
[addressing anemia and hemolysis in G6PD deficiency with biliary concerns]
An ultrasound performed on 2024-08-27, revealed the presence of gallstones (GB sludge), fluid collection near the gallbladder, and minimal ascites between the liver and the left lobe of the liver. As well as other lab results listed below:
2024-08-28 Bilirubin total 1.35 mg/dL
2024-08-28 Bilirubin direct 0.31 mg/dL
2024-08-26 FLEAR/CD24 Type III <0.1 %
2024-08-26 FLEAR/CD24 Type II <0.1 %
2024-08-26 FLEAR/CD16 Type III <0.1 %
2024-08-26 FLEAR/CD16 Type II <0.1 %
2024-08-28 HGB 7.1 g/dL
2024-08-26 HGB 7.9 g/dL
2024-08-24 HGB 6.5 g/dL
2024-08-24 HGB 6.6 g/dL
2024-08-22 HGB 7.0 g/dL
2024-08-20 HGB 8.0 g/dL
2024-08-19 HGB 9.6 g/dL
2024-08-26 CRP 27.5 mg/dL
2024-08-24 CRP 17.1 mg/dL
2024-08-24 G-6-P-D 0.2 U/gHb
2024-08-22 Haptoglobin <5.81 mg/dL
2024-08-21 Haptoglobin <5.81 mg/dL
2024-08-21 Ferritin; 1971.6 ng/mL
2024-08-20 Fe (Iron-bound) 142 ug/dL
2024-08-20 TIBC 207 ug/dL
2024-08-20 UIBC 65 ug/dL
2024-08-20 Reticulocyte Ratio 9.210 %
Comments:
Recommended Actions:
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
[exam findings]
[MedRec]
[surgical operation]
[exam findings]
[MedRec]
[chemotherapy]
2024-08-27 - (FOLFOX)
2024-08-06 - (FOLFOX)
2024-07-10 - (FOLFOX)
2024-06-18 - (FOLFOX)
2024-05-28 - (FOLFOX)
2024-04-17
2024-04-11
2024-03-19
2024-02-27
2024-02-20
2024-01-31
2024-01-17
2024-01-10 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + NS 500mL 2hr (before CDDP) + cisplatin 50mg/m2 50mg NS 500mL 2hr + NS 500mL 2hr (after CDDP) (Two weeks on, one week off)
2023-12-27 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + NS 500mL 2hr (before CDDP) + cisplatin 50mg/m2 50mg NS 500mL 2hr + NS 500mL 2hr (after CDDP)
2023-12-20 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + NS 500mL 2hr (before CDDP) + cisplatin 50mg/m2 50mg NS 500mL 2hr + NS 500mL 2hr (after CDDP)
2023-12-05 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + NS 500mL 2hr (before CDDP) + cisplatin 50mg/m2 50mg NS 500mL 2hr + NS 500mL 2hr (after CDDP)
2023-11-29 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + cisplatin 50mg/m2 50mg NS 500mL 1hr (gemcitabine + cisplatin; Q4W)
[considering next steps as tumor markers rise and metastases increase]
Over the past three months, CA199 levels have doubled, and CEA has tripled (though CA199 has been above the reference range, while CEA remains within it). Additionally, the CT scan on 2024-08-21 suggests possible carcinomatosis, right pleura metastases, and multiple lung metastases with mild increases in size. Overall, the disease appears to be progressing slowly, even after the initiation of FOLFOX in May 2024.
Lab results indicate decreased renal function (eGFR 52, with no rapid deterioration), normal liver function, anemia (HGB 9.4 g/dL), and suboptimal but acceptable blood sugar control.
No current medication issues have been identified. It may be time to consider the next line of treatment or regimen adjustments if the disease shows signs of rapid progression.
2024-08-09 CA-199 (NM) 64.092 U/ml
2024-07-12 CA-199 (NM) 41.629 U/ml
2024-06-20 CA-199 (NM) 37.733 U/ml
2024-05-29 CA-199 (NM) 32.722 U/ml
2024-05-03 CA-199 (NM) 25.762 U/ml
2024-04-17 CA-199 (NM) 24.911 U/ml
2024-04-12 CA-199 (NM) 28.871 U/ml
2024-04-03 CA-199 (NM) 24.195 U/ml
2024-03-27 CA-199 (NM) 19.936 U/ml
2024-03-22 CA-199 (NM) 24.314 U/ml
2024-03-12 CA-199 (NM) 22.997 U/ml
2024-03-08 CA-199 (NM) 18.399 U/ml
2024-03-01 CA-199 (NM) 23.074 U/ml
2024-02-06 CA-199 (NM) 28.001 U/ml
2024-02-02 CA-199 (NM) 29.461 U/ml
2024-01-25 CA-199 (NM) 25.929 U/ml
2024-01-12 CA-199 (NM) 33.372 U/ml
2024-08-09 CEA (NM) 2.847 ng/ml
2024-07-12 CEA (NM) 1.328 ng/ml
2024-06-20 CEA (NM) 1.247 ng/ml
2024-05-29 CEA (NM) 0.972 ng/ml
2024-05-03 CEA (NM) 0.933 ng/ml
2024-04-17 CEA (NM) 0.574 ng/ml
[combining immunotherapy with chemotherapy in biliary tract tumors] - Ref: 2024-01-16 - https://www.uptodate.com/contents/systemic-therapy-for-advanced-cholangiocarcinoma
The current treatment regimen for advanced or metastatic biliary tract tumors for this patient is gemcitabine plus cisplatin.
Adding durvalumab to this regimen, as seen in the TOPAZ-1 trial, can enhances OS and response, without notably increasing toxicity. Similarly, pembrolizumab combined with gemcitabine and cisplatin, as demonstrated in the KEYNOTE-966 trial, also improves OS and is well-tolerated.
However, due to non-coverage by NHI and potential reimbursement issues, the addition of durvalumab or pembrolizumab may be more suitable for patients who can financially manage the costs.
[hyperuricemia, hyperkalemia, hypercalcemia]
Hyperuricemia, hyperkalemia, hypercalcemia were observed.
Hyperuricemia is treated with Fasturtec (rasburicase), Februic (febuxostat) and Rolikan (sodium bicarbonate).
Hyperkalemia is treated wtih Kalimate (calcium polystyrene sulfonate).
Hyperuricemia and hyperkalemia are frequent symptoms of tumor lysis syndrome. Another typical symptom is hyperphosphatemia, so it’s recommended to also monitor serum phosphate levels.
Hypercalcemia is treated with Miacalcic (calcitonin).
For severe hypercalcemia, the maintenance dose of calcitonin can be up to 8 units/kg (2023-11-29 70kg => 560 units) Q6H to Q12H, starting with an initial dose of 4 units/kg (280 units) Q12H. Since the current administration of 100 IU Q6H is below the recommended dosage, this might extend the duration of therapy. It’s advisable to limit calcitonin therapy to a period of 24 to 48 hours to avoid tachyphylaxis.
Given that the serum calcium level has exceeded 3.5 mmol/L (14 mg/dL) and if the reading does not obviously trend downwards, the combined use of calcitonin with bisphosphonates for a longer effect might be an option.
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
[improvement in renal function after switch to carboplatin from cisplatin in PF regimen and monitoring electrolytes]
Since 2024-07-18, the platinum component in the PF regimen has been switched from cisplatin to carboplatin, with the patient’s eGFR improving from 40 ml/min/1.73m² on 2024-07-05 to 90 ml/min/1.73m² on 2024-08-21. Other lab results on 2024-08-21 were generally normal.
However, it is noteworthy that since July, hypokalemia has been more frequent, with potassium levels dropping below 3.5 mmol/L and even below 3.0 mmol/L at times. This may indicate a declining ability to maintain electrolyte balance. The patient is currently receiving appropriate oral potassium supplementation for hypokalemia and Baraclude (entecavir) for HBV reactivation prevention, with no medication issues identified.
2024-08-21 eGFR 90.01 ml/min/1.73m^2
2024-08-13 eGFR 87.76 ml/min/1.73m^2
2024-08-04 eGFR 72.16 ml/min/1.73m^2
2024-07-18 eGFR 93.60 ml/min/1.73m^2
2024-07-15 eGFR 70.66 ml/min/1.73m^2
2024-07-10 eGFR 54.51 ml/min/1.73m^2
2024-07-05 eGFR 40.71 ml/min/1.73m^2
2024-06-18 eGFR 91.18 ml/min/1.73m^2
2024-08-21 K (Potassium) 4.0 mmol/L
2024-08-13 K (Potassium) 2.7 mmol/L
2024-08-04 K (Potassium) 3.9 mmol/L
2024-07-18 K (Potassium) 3.3 mmol/L
2024-07-15 K (Potassium) 2.7 mmol/L
2024-07-10 K (Potassium) 3.1 mmol/L
2024-07-05 K (Potassium) 4.0 mmol/L
[reconciliation]
Lab assessments conducted on 2024-03-25 indicated mostly normal results, with the exception of hypomagnesemia (1.6 mg/dL), which are being managed with oral MgO supplements. The patient’s vital signs have also consistently been stable during their hospitalization. Given these findings, there seems to be no contraindication to continuing with the current PF4 treatment regimen.
Cisplatin is assciated with the potential hematologic and oncologic side effects as the following (ref: UpToDate)
Reducing the dosage of cisplatin (which is dose-dependent) can alleviate thrombocytopenia. Although the patient’s decrease in neutrophils and hemoglobin is not as significant as the decrease in platelets, platelet transfusions may trigger immune responses, infections, and other complications. Therefore, a balance between the expected therapeutic effect and adverse reactions should be sought while considering treatment options. One possible approach is to first reduce the cisplatin dosage to a level where the patient’s platelet count can still recover, and then proceed with further consideration.
Recent lab data showed a significant downward trend in PLT, indicating that the patient has developed thrombocytopenia. Please closely monitor the patient for any signs of bleeding.
Actively bleeding patients with thrombocytopenia should be transfused with platelets immediately to keep platelet counts >50K/uL in most bleeding situations including disseminated intravascular coagulation (DIC), and >100K/uL if there is central nervous system bleeding. (ref: Guidelines for the diagnosis and management of disseminated intravascular coagulation. British Committee for Standards in Haematology. Br J Haematol. 2009;145(1):24-33. doi:10.1111/j.1365-2141.2009.07600.x)
The patient had a marginally high uric acid level (2022-07-05 7.7 mg/dL) prior to last chemotherapy, which could be followed up in order to determine the need for an uric acid lowering drug (e.g. febuxostat).
EBV DNA PCR results on 2022-01-17 indicated equivocal 120 copies/mL, which could be updated as well.
There is no issue with active prescriptions.
For nonkeratinizing and/or undifferentiated histology, consider testing for EBV in tumor and blood. The EBV DNA load may reflect prognosis and change in response to therapy.
Stereotactic proton radiosurgery might be effective in treating brain metastases. reference: Proton Stereotactic Radiosurgery for Brain Metastases. https://pubmed.ncbi.nlm.nih.gov/29976494/
5-Fu plus cisplatin has been the current regimen since 2022-03-18. PD-1 inhibitors (e.g. pembrolizumab or nivolumab) might be an additional treatment option for cancers that are recurrent, unresectable, or metastatic (without surgery or radiation therapy).
Chronic viral hepatitis B is managed with Baraclude (entecavir) currently.
[exam findings]
[MedRec]
[radiotherapy]
[chemotherapy]
[frequently neutropenia despite reduced oxaliplatin dosage]
Granocyte (lenograstim 250ug) was administered on 2024-08-26, and currently, there is no evidence of neutropenia.
This patient appears to have a tendency towards neutropenia with the FOLFOX regimen. Despite oxaliplatin being used at only half the standard dose initially, and further reduced to 40% since late June, neutropenia continues to be frequently observed.
2024-08-27 WBC 6.54 x10^3/uL
2024-08-26 WBC 1.86 x10^3/uL
2024-08-27 Neutrophil 87.3 %
2024-08-26 Neutrophil 78.3 %
[febuxostat treatment for hyperuricemia]
The patient’s elevated serum uric acid levels are being managed with Feburic (febuxostat). The treatment is well-tolerated, and no issues or adverse effects have been identified.
[WBC count returns to normal after neutropenia]
Neutropenia has resolved, and the WBC count is now within the normal range.
2024-08-10 WBC 6.69 x10^3/uL
2024-08-09 WBC 1.59 x10^3/uL
2024-08-10 Neutrophil 90.6 %
2024-08-09 Neutrophil 64.8 %
[potential impact of earlier radiotherapy on pancytopenia; assessing patient tolerance to transfusion and G-CSF]
Lab data showed persistent pancytopenia, with fluctuations in severity but almost never returning to normal levels. Even on the day of receiving CCRT on 2024-02-08, the values were below normal, suggesting that earlier radiotherapy (from 2024-02-01) may also be a contributing factor. The patient began neoadjuvant FOLFOX treatment on 2024-03-30 (with all three sessions at a reduced dose), and pancytopenia has worsened since then.
If the patient tolerates LPRBC or LRP transfusion and G-CSF administration, the reduced dose regimen might be continued. However, if the patient cannot tolerate it and there is no substantial improvement in pancytopenia, alternative regimens or treatment approaches may need to be considered.
2024-06-03 WBC 2.33 x10^3/uL Neutrophil 83.2 %
2024-05-31 WBC 1.43 x10^3/uL Neutrophil 81.0 %
2024-05-27 WBC 1.80 x10^3/uL Neutrophil 68.4 %
2024-05-09 WBC 2.29 x10^3/uL Neutrophil 75.5 %
2024-04-15 WBC 2.35 x10^3/uL
2024-04-08 WBC 1.86 x10^3/uL
2024-03-29 WBC 2.64 x10^3/uL
2024-03-25 WBC 2.12 x10^3/uL
2024-03-18 WBC 2.32 x10^3/uL
2024-02-20 WBC 3.94 x10^3/uL
2024-02-15 WBC 2.81 x10^3/uL
2024-02-08 WBC 2.77 x10^3/uL
2024-06-03 HGB 13.9 g/dL
2024-05-31 HGB 7.1 g/dL
2024-05-27 HGB 11.2 g/dL
2024-05-09 HGB 9.9 g/dL
2024-04-15 HGB 9.7 g/dL
2024-04-08 HGB 10.7 g/dL
2024-03-29 HGB 10.0 g/dL
2024-03-25 HGB 11.0 g/dL
2024-03-18 HGB 11.4 g/dL
2024-02-20 HGB 11.5 g/dL
2024-02-15 HGB 11.4 g/dL
2024-02-08 HGB 11.9 g/dL
2024-06-03 PLT 61 *10^3/uL
2024-05-31 PLT 44 *10^3/uL
2024-05-27 PLT 62 *10^3/uL
2024-05-09 PLT 59 *10^3/uL
2024-04-15 PLT 68 *10^3/uL
2024-04-08 PLT 75 *10^3/uL
2024-03-29 PLT 65 *10^3/uL
2024-03-25 PLT 59 *10^3/uL
2024-03-18 PLT 56 *10^3/uL
2024-02-20 PLT 86 *10^3/uL
2024-02-15 PLT 79 *10^3/uL
2024-02-08 PLT 85 *10^3/uL
{colon cancer - mucinous adenocarcinoma}
[lab data]
2020-09-30 NRAS/KRAS detected
2020-09-30 KRAS 12/13 Not detected
2020-09-30 BRAF Not detected
2020-08-28 HBsAg (NM) Negative
2020-08-28 HBsAg Value (NM) 0.365
2020-08-28 Anti-HBs (NM) Negative
2020-08-28 Anti-HBs value (NM) <2.00
2020-08-28 Anti-HBc (NM) Negative
2020-08-28 Anti-HBc Value (NM) 2.15
2020-08-28 Anti-HCV (NM) Negative
2020-08-28 Anti-HCV Value (NM) 0.0382
2020-08-28 HBsAg (NM) Negative
2020-08-28 HBsAg Value (NM) 0.365
2020-08-28 Anti-HBs (NM) Negative
2020-08-28 Anti-HBs value (NM) <2.00
2020-08-28 Anti-HBc (NM) Negative
2020-08-28 Anti-HBc Value (NM) 2.15
2020-08-28 Anti-HCV (NM) Negative
2020-08-28 Anti-HCV Value (NM) 0.0382
[exam findings]
[consultation]
[surgical operation]
[immunochemotherapy]
2024-08-12 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + irinotecan 150mg/m2 270mg D5W 250mL 1.5hr + leucovorin 400mg/m2 700mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr (Cyramza + FOLFIRI)
2024-06-18 - ………………………………… irinotecan 150mg/m2 270mg D5W 250mL 1.5hr + leucovorin 400mg/m2 700mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 4300mg NS 500mL 48hr (infusor) (Cyramza + FOLFIRI)
2024-06-03 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + irinotecan 150mg/m2 240mg D5W 250mL 1.5hr + leucovorin 400mg/m2 700mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (Cyramza + FOLFIRI)
2024-05-17 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + irinotecan 150mg/m2 240mg D5W 250mL 1.5hr + leucovorin 400mg/m2 700mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (Cyramza + FOLFIRI)
2024-04-23 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + irinotecan 120mg/m2 200mg D5W 250mL 1.5hr + leucovorin 400mg/m2 700mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (Cyramza + FOLFIRI)
2024-04-08 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + irinotecan 120mg/m2 200mg D5W 250mL 1.5hr + leucovorin 400mg/m2 700mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (Cyramza + FOLFIRI. Due to WBC 2700, ANC 1582, DC bolus 5-FU this time)
2024-03-25 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + irinotecan 120mg/m2 200mg D5W 250mL 1.5hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (Cyramza + FOLFIRI)
2024-03-07 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + irinotecan 120mg/m2 200mg D5W 250mL 1.5hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (Cyramza + FOLFIRI)
2024-02-15 - ………………………………… irinotecan 120mg/m2 200mg D5W 250mL 1.5hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFIRI)
2023-12-20 - Mitonco (mitomycin-C) 35mg/m2 60mg NS 100mL 90min IP
2023-10-17 - (Avastin + FOLFOX)
2023-09-26 - (Avastin + FOLFOX)
2023-09-12 - (Avastin + FOLFOX)
2023-08-29 - (Avastin + FOLFOX)
2023-08-15 - (Avastin + FOLFOX)
2023-08-02 - (Avastin + FOLFOX)
2023-07-18 - (Avastin + FOLFOX)
2023-07-04 - (Avastin + FOLFOX)
2023-06-21 - (Avastin + FOLFOX)
2023-06-06 - (Avastin + FOLFOX)
2023-05-23 - (Avastin + FOLFOX)
2023-05-09 - (Avastin + FOLFOX)
2023-04-25 - (Avastin + FOLFOX)
2023-04-07 - (Avastin + FOLFOX)
2023-03-21 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (Avastin + FOLFOX)
2023-03-07 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (Avastin + FOLFOX)
2023-02-20 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (Avastin + FOLFOX)
2023-01-30 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (Avastin + FOLFOX)
2022-12-26 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (Avastin + FOLFOX)
2021-03-30 - ………………………………….. irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (_______ + FOLFIRI)
2021-03-16 - ………………………………….. irinotecan 150mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (_______ + FOLFIRI)
2021-03-02 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 150mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (Avastin + FOLFIRI)
2021-02-17
2021-01-26
2021-01-12
2020-12-30
2020-12-15
2020-11-27
2020-11-10
2020-10-27
2020-10-13
2020-09-23
[rising CEA and CA199 with potential GI bleeding management]
CEA and CA199 levels have doubled since August, and an excision of an abdominal malignant soft tissue tumor was performed on 2024-07-10.
Additionally, HGB levels have been trending downward over the past quarter, possibly due to gastrointestinal bleeding (stool FOB positive on 2024-08-13). A transfusion was administered on 2024-08-25. If evidence of GI bleeding persists, the addition of PPI and/or tranexamic acid may be considered.
2024-08-21 CEA 1122.95 ng/mL
2024-08-06 CEA 1005.44 ng/mL
2024-06-13 CEA 386.22 ng/mL
2024-05-02 CEA 418.95 ng/mL
2024-04-22 CEA 362.09 ng/mL
2024-08-21 CA199 209.91 U/mL
2024-08-06 CA199 221.02 U/mL
2024-06-13 CA199 92.07 U/mL
2024-05-02 CA199 100.40 U/mL
2024-04-22 CA199 96.31 U/mL
2024-08-25 HGB 8.7 g/dL
2024-08-21 HGB 8.3 g/dL
2024-08-12 HGB 8.1 g/dL
2024-08-06 HGB 9.9 g/dL
2024-07-30 HGB 9.7 g/dL
2024-07-17 HGB 10.2 g/dL
2024-07-02 HGB 10.4 g/dL
2024-06-18 HGB 10.2 g/dL
2024-06-13 HGB 10.5 g/dL
2024-05-28 HGB 10.1 g/dL
2024-05-17 HGB 10.2 g/dL
2024-05-02 HGB 11.8 g/dL
[CEA and CA199 trends support continued treatment]
Decreasing levels of the tumor markers CEA and CA199 have been observed.
Lab results from 2024-04-22 were grossly within normal limits, indicating no evidence of contraindications for proceeding with chemotherapy.
2024-04-22 CEA 362.09 ng/mL
2024-03-26 CEA 456.30 ng/mL
2024-04-22 CA199 96.31 U/mL
2024-03-26 CA199 117.22 U/mL
Pathology results from the extensive resection of a soft tissue tumor on 2023-12-21 confirmed recurrent mucinous adenocarcinoma. A subsequent abdominal CT scan on 2024-01-19 suggested metastasis. Due to these findings, the treatment regimen was changed to Cyramza + FOLFIRI, initiated on 2024-02-15. Encouragingly, both CEA and CA199 tumor markers have shown a continuous decline since starting the new regimen, suggesting its effectiveness.
2024-03-26 CEA 456.30 ng/mL
2024-03-19 CEA 594.94 ng/mL
2024-02-26 CEA 942.43 ng/mL
2024-03-26 CA199 117.22 U/mL
2024-03-19 CA199 141.97 U/mL
2024-02-26 CA199 182.41 U/mL
However, while the bolus dose of 5-FU was omitted this time due to an ANC of 1582, please continue to monitor for any signs of infection.
Between 2020-09 and 2021-03, the patient received bevacizumab + FOLFIRI, and her CEA levels remained within the normal range. After completing the FOLFIRI treatment, the CEA levels began to rise slowly, but no imaging evidence was found until a CT scan on 2022-12-22, which revealed soft tissues in the peritoneal cavity suspected to be tumor seeding. A new regimen of bevacizumab + FOLFOX was initiated on 2022-12-26, and a subsequent decrease in CEA levels was observed, suggesting the effectiveness of the new treatment.
No medication reconciliation issue was identified in the patient.
[exam findings]
[MedRec]
[chemotherapy]
Chemotherapy regimens for metastatic pancreatic cancer: FOLFIRINOX - 2024-02-16 - https://www.uptodate.com/contents/image?imageKey=ONC%2F79571
Cycle length: 14 days.
Regimen
Modified FOLFIRINOX chemotherapy for pancreatic cancer - 2024-02-16 - https://www.uptodate.com/contents/image?imageKey=ONC%2F109546
Cycle length: 14 days.
Regimen
[stable disease and consistent CA199 levels under FOLFIRINOX]
A CT scan on 2024-08-03, compared to 2024-04-18, showed stable disease. CA-199 levels have remained around 500 U/mL over the past 2 months, and other lab results on 2024-08-24 were generally normal. The patient is tolerating the FOLFIRINOX regimen well, and no medication issues have been identified.
Abdominal CT scan performed on 2024-04-18, revealed stable pancreatic body cancer without further invasion into adjacent structures. Additionally, lab results showed a continued decline in CA-199 levels. These findings suggest that the current FOLFIRINOX treatment regimen is still effective.
No medication discrepancies were identified.
[clearance for 4th FOLFIRINOX session based on lab results]
Laboratory tests conducted on 2024-03-28 showed all key indicators, including blood counts, electrolytes, and liver and kidney functions, were grossly within normal ranges, allowing for the 4th session of FOLFIRINOX to proceed without medical objections.
A comprehensive examination of the patient’s medication list in both the HIS5 and PharmaCloud databases confirmed consistency and accuracy.
[reconciliation]
The CA-199 level has declined relative to the previous month’s data. Laboratory results from 2024-03-06 were generally within normal limits, leading to the administration of the third cycle of FOLFIRINOX on the same day.
A thorough review of the HIS5 and PharmaCloud databases revealed no discrepancies in medication.
[rising CA-199 in newly-started FOLFIRINOX Regimen, further investigation needed. unremarkable labs & no med discrepancies]
This patient initiated FOLFIRINOX treatment in late 2024-01 and the current hospitalization pertains to the second cycle. While other lab findings on 2024-02-15 were unremarkable and no medication discrepancies were identified, ongoing elevation of the tumor marker CA-199 warrants further investigation.
[lab data]
Bone marrow cell morphology and cell count
Hepatitis B and C
[exam findings]
[MedRec]
[consultation]
[MultiTeam]
[chemotherapy]
Lab results
The CMV viral load has tested positive. Several agents are available for systemic CMV therapy, including ganciclovir, valganciclovir, foscarnet, and cidofovir. However, the latter two are not available at this hospital. Below are the two available treatment options for your consideration:
[ongoing management of pancytopenia post-allo PBSCT]
The patient remains in a state of pancytopenia, with the allo PBSCT blood stem cells not yet fully restoring expected function (2024-07-26 STR DNA fingerprint showed 100% recipient’s type). The patient continues to receive G-CSF, transfusions, and antibiotics. Renal function remains stable, though liver enzyme levels are showing signs of increase. BaoGan (silymarin) might be beneficial. No other issues with the current medication regimen have been identified.
[verifying blood draw times for correct trough concentrations - tacrolimus TDM]
According to HIS5 nursing medication records, the first dose on 2024-08-01 was administered at 09:23, with the system showing the blood draw time at 10:12. If the measurement is intended to obtain the trough concentration, the correct blood draw time should be within half an hour before administration. Please verify the accuracy of the blood draw time.
If the system’s recorded time is incorrect but the actual blood draw time was accurate, it is recommended to increase the dose of Prograf (tacrolimus 1mg) to 5# BID to achieve the target concentration range of 5 ng/mL to 20 ng/mL.
[confirming accurate blood draw times in isolation room procedures]
After a phone call with the primary nurse, it was confirmed that the actual blood draw time was accurate. The delay in barcode scanning was due to the inconvenience of leaving the isolation room at the time of the blood draw.
[evaluating tacrolimus dosage for optimal concentration and monitoring WBC levels]
There is currently no record of diarrhea (diarrhea has resolved). The tacrolimus level increased to 4.4 ng/mL on 2024-07-29, which is closer to the lower limit of the recommended range of 5 ng/mL. According to the nursing medication and TDM records, the blood draw was conducted approximately 4 hours before the medication administration. If the records are accurate, the actual trough concentration might be even lower.
Increasing Prograf (tacrolimus 1mg) to 5# BID could be considered to reach the recommended concentration range. Alternatively, the dosage may remain unchanged, but the patient should be closely monitored for any signs of acute graft-versus-host disease based on clinical status.
WBC levels have dropped again, and filgrastim administration is ongoing.
[transfusion update and acute GVHD considerations]
Another transfusion of LPRBC and LRP was conducted on 2024-07-25 to replenish deficient HGB and PLT levels. The WBC count was 0.19 x10^3/uL, still below the target value, so filgrastim 300ug is being administered daily.
According to the progress note, the patient experienced diarrhea 7-8 times yesterday, which might indicate gastrointestinal symptoms of acute GVHD. If confirmed, adjusting tacrolimus to meet the recommended trough level may be considered.
[Monitoring Post-Transplant WBC Recovery and Tacrolimus Levels]
Today (2024-07-23) marks day 19 since the transplantation. An increase in WBC count is now evident. Liver and kidney function indicators are generally within normal ranges. However, recent tacrolimus levels have not reached the recommended range, and a dosage increase might be considered.
[adjusting tacrolimus dosage for optimal levels - TDM]
The patient is currently on Prograf (tacrolimus 1mg) 3# BID. A trough level test on 2024-07-22 showed 2.8 ng/mL, which is below the recommended range of 5-20 ng/mL. The dosage might be increased to 4# BID to reach the target level and reduce the risk of graft-versus-host disease.
[management of oral ulceration (tongue tie) in this neutropenic patient
]
The patient has developed an ulcer on the tongue tie. Currently, she is still in a neutropenic phase, which makes the use of Nincort Oral Gel (triamcinolone), due to its immunosuppressive effects, not recommended as it could further elevate the risk of infections. An alternative could be Parmason Gargle Solution (chlorhexidine) for oral rinsing and oropharyngeal decontamination.
[managing suboptimal tacrolimus trough levels in GVHD]
Tacrolimus is used for graft-versus-host disease (GVHD) management.
For this patient, the initial oral tacrolimus should have been calculated as 0.12 mg/kg/day times 56 kg, equaling 6.72 mg/day. The actual regimen was 1mg twice daily (2mg total per day), with a trough level on 2024-07-12 of 1.3 ng/mL, which is below the recommended range of 5-20 ng/mL. It is advised to increase the dose to 3# BID and recheck the trough level 3 days after this adjustment.
The findings presented in the article provide evidence to support the aforementioned recommendation. “Early Post-Transplantation Tacrolimus Levels Correlate with Acute Graft-Versus-Host Disease in Allogeneic Hematopoietic Stem Cell Transplantation from Related and Unrelated Donors” - https://ashpublications.org/blood/article/128/22/3429/97989/Early-Post-Transplantation-Tacrolimus-Levels
[CMV prevention strategies in allogeneic transplant for AML]
Today at 10:00 in the ward meeting room, the attending physician Dr Gao conducted a family meeting for this patient with AML, detailing the risks of allogeneic transplantation and its significance as a treatment option.
Regarding CMV infection prevention discussed during the meeting, I have gathered the following information, which may be useful for the attending physician and nurse practitioner for reference.
UpToDate suggests that for CMV prevention - initial (induction) pre-emptive therapy, one of the following agents may be used:
Ganciclovir (available) 5 mg/kg IV every 12 hours
Valganciclovir (available) 900 mg orally twice daily is an acceptable alternative for patients who can tolerate oral therapy, especially in patients at low risk for CMV disease and who have low viral loads
Foscarnet (not available in this hospital) 60 mg/kg IV every 8 hours is an alternative for patients who cannot take ganciclovir or valganciclovir
Letermovir (available, temporary purchase item) is a potential alternative that has considerably less toxicity. It has not been studied for this indication in HCT recipients, but, in a phase IIa study in renal transplant recipients, letermovir pre-emptive therapy was found to be promising.
Maribavir (not available in this hospital) is a potential alternative to valganciclovir with similar efficacy but has more gastrointestinal toxicity and less myelosuppression.
[initiating posaconazole treatment]
According to the Sanford Guide, posaconazole should be administered with a loading dose of 300 mg BID for two doses, then switching to a maintenance dose of 300 mg QD.
[lab data]
2023-06-19 JAK2 single site mutation Undetectable
2023-06-14 HBsAg (NM) Negative
2023-06-14 HBsAg Value (NM) 0.392
2023-06-14 Anti-HCV (NM) Negative
2023-06-14 Anti-HCV Value (NM) 0.047
2023-06-14 Anti-HBc (NM) Positive
2023-06-14 Anti-HBc Value (NM) 0.009
2023-06-14 Anti-HBs (NM) Negative
2023-06-14 Anti-HBs value (NM) 4.930 mIU/mL
2023-03-13 CK 14 U/L
2023-03-03 Zinc,Zn 648 ug/L
2023-02-16 ANA Homogeneous 1:1280; Speckled 1:1280
2023-02-15 Anti-ds DNA Antibody 5.6 IU/ml
2023-02-15 Anti-ENA(Jo-1) EliA U/ml
2023-02-15 Anti Jo-1 antibody 0.3 EliA U/ml
2023-02-15 Anti-ENA (Scl-70) EliA U/ml
2023-02-15 Anti-ENA Scl-70 Ab 2.0 EliA U/ml
2023-02-14 ESR 31 mm/hr
2023-02-09 CK 10 U/L
2021-05-15 ESR 45 mm/hr
2021-03-17 LA1 52.8 sec
2021-03-17 LA2 38.0 sec
2021-03-17 LA1/LA2 ratio 1.1
2021-03-13 ESR 33 mm/hr
2020-07-04 Ferritin 101.9 ng/mL
2020-05-20 ESR 44 mm/hr
2020-05-14 Aspergillus Ag Negative
2020-05-14 Aspergillus Ag Value 0.13 Ratio
2020-05-06 LA1 51.4 sec
2020-05-06 LA2 39.4 sec
2020-05-06 LA1/LA2 ratio 1.1
2020-05-05 Anti-beta2-glycoprotein-I Ab 3.5 U/mL
2020-05-05 Anti-cardiolipin-IgM 3.0 MPL U/mL
2020-05-05 Anti-cardiolipin IgG GPL-U/mL
2020-05-05 Anti-Cardiolopin 8.0 GPL-U/mL
2020-05-05 Anti-ENA Sm 7.0 EliA U/ml
2020-05-05 Anti-ENA RNP 2.4 EliA U/ml
2020-05-05 Anti-ds DNA Antibody 14 IU/ml
2020-05-05 C4 30.4 mg/dL
2020-05-05 C3 102.8 mg/dL
2020-04-20 Aspergillus Ag Positive
2020-04-20 Aspergillus Ag Value 0.5 Ratio
2020-04-20 Anti-ENA SS-A (Ro) >2400 EliA U/ml
2020-04-20 Anti-ENA SS-B (La) >3200 EliA U/ml
2020-04-20 ANA Homogeneous ; 1:1280
2020-04-17 Cryptococcus Ag Negative
2020-04-17 Antibody Identification Anti-M
2020-04-15 Anti-ENA Sm 7.5 EliA U/ml
2020-04-15 Anti-ENA RNP 2.4 EliA U/ml
2020-04-15 Anti-ds DNA Antibody 14 IU/ml
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
[resumption of Vidaza treatment and skin symptom management, monocyte fluctuations during ongoing treatment]
The planned monthly Vidaza (azacitidine) treatment was skipped in July and restarted on 2024-08-22, with acceptable lab results on the same day.
Medications prescribed by the dermatologist for her skin symptoms have been integrated into the active medication list, with no issues identified.
Monocyte levels have fluctuated significantly throughout the treatment, with a current reading of 20%, 1.3 K/uL during this hospitalization.
Lab Date WBC K/uL Monocyte % Monocyte /uL
2024-08-22 6.34 19.9 1262
2024-08-10 9.64 39 3760
2024-07-30 13.35 40.6 5420
2024-07-21 11.92 41.9 4994
2024-07-05 3.18 25 795
2024-06-25 10.73 37.6 4034
2024-06-19 11.72 72.5 8497
2024-05-31 4.54 21.2 962
2024-05-23 10.56 37.5 3960
2024-05-20 10.85 43.7 4741
2024-04-29 3.17 10.7 339
2024-04-22 7.41 13.3 986
2024-04-16 21.2 60.7 12868
2024-04-09 4.06 69 2801
2024-04-02 0.4 0 0
2024-03-28 1.3 4.7 61
2024-03-20 5.65 18.6 1051
2024-03-18 5.24 9 472
2024-03-15 5.75 22.2 1277
2024-03-13 6.1 28.9 1763
[azacitidine skin reactions is managed]
Skin symptoms have developed following the administration of azacitidine during this and the previous hospitalization. Currently, Allegra (fexofenadine) is being used to manage these symptoms, with observation to assess control effectiveness.
Azacitidine may cause various dermatologic issues such as ecchymoses (31%), erythema (7%-17%), pruritus (12%), and rashes (10%-14%). For subcutaneous injections, it is advised to rotate injection sites (upper arms, thighs, or abdomen) to avoid complications. New injection sites should be at least 2.5 cm apart from previous ones, and injections should not be administered into areas that are tender, bruised, red, or hardened.
Recent lab results from 2024-04-16 show a WBC count of 21.2K, a neutrophil percentage of 26.2%, an estimated ANC of 5.55K, and stable temperatures not exceeding 37 degrees Celsius.
Xerostomia is being treated with Evoxac (cevimeline), Plaquenil (hydroxychloroquine), and Celebrex (celecoxib), with no discrepancies in medication found.
[initiating azacitidine for CMML-MDS, monitoring respiratory risks]
Chronic Myelomonocytic Leukemia-Myelodysplastic Syndrome (CMML-MDS) is likely, given that the dysplastic characteristic (WBC frequently < 13K/uL). Hypomethylating agents such as azacitidine and decitabine have been shown to provide symptomatic relief in patients with CMML, particularly for symptoms related to cytopenia. In this instance, azacitidine treatment was initiated on 2024-03-14 at a standard dosage of 75 mg/m2/day for 7 days within a 28-day treatment cycle. Renal and liver functions were reviewed and, based on the laboratory data from 2024-03-13, are deemed adequate to tolerate this dosage.
Subsequent cycles might planned at 75 mg/m2/day for 7 days every 4 weeks. The dosage might be increased to 100 mg/m2/day if no improvement is observed after 2 cycles and no significant toxicity is noted beyond nausea and vomiting.
A Network Meta-Analysis comparing azacitidine (AZA) and decitabine (DAC) found no statistically significant differences in efficacy, although DAC showed a higher CR rate than AZA in patients with both AML and MDS. There appears to be no clear superiority between the two agents regarding response rates. However, patients receiving DAC experienced more frequent grade 3/4 cytopenias, notably anemia, febrile neutropenia, and leukopenia, compared to those receiving AZA treatment. (Ref: Ma J, Ge Z. Comparison Between Decitabine and Azacitidine for Patients With Acute Myeloid Leukemia and Higher-Risk Myelodysplastic Syndrome: A Systematic Review and Network Meta-Analysis. Front Pharmacol. 2021 Aug 17;12:701690. doi: 10.3389/fphar.2021.701690. Erratum in: Front Pharmacol. 2023 May 05;14:1213053.)
The patient has a history of chronic respiratory symptoms and records of consultations with chest medicine. It is important to closely monitor for respiratory system infections, particularly when chemotherapy leads to a decrease in WBC count.
Based on the PharmaCloud database, our hospital is the sole medical provider for the patient in the past 3 months. No issues related to medication reconciliation have been identified.
Cyclophosphamide is a potential therapeutic option for severe, refractory cases of dermatomyositis/polymyositis, and it is often administered as an adjunctive treatment. The recommended oral dose typically ranges from 1.5 to 2 mg/kg/day (ref: UpToDate). As of 2023-06-18, the patient’s body weight is 53.3kg, and the current prescription of cyclophosphamide at 50mg QD is below the suggested dosage range. Please continue to monitor the treatment’s effectiveness and consider whether a dose adjustment might be required.
[MedRec]
[assessing anemia and thrombocytopenia with elevated FKLC]
Anemia, thrombocytopenia, elevated free kappa light chain, and normal levels of serum IgG, IgA, IgM, and IgE were observed. Possible causes include aplastic anemia or multiple myeloma, and a bone marrow biopsy has been arranged.
Underlying conditions are being managed with medications from the active list, and no discrepancies have been identified.
2024-08-21 HGB 7.2 g/dL **
2024-08-19 HGB 6.7 g/dL ***
2024-08-12 HGB 8.1 g/dL *
2024-08-05 HGB 9.3 g/dL
2024-08-05 HGB 8.8 g/dL *
2024-08-05 HGB 5.3 g/dL ****
2024-06-11 HGB 9.3 g/dL
2024-03-04 HGB 9.3 g/dL
2024-08-21 PLT 101 *10^3/uL
2024-08-19 PLT 119 *10^3/uL
2024-08-12 PLT 108 *10^3/uL
2024-08-05 PLT 98 *10^3/uL
2024-08-05 PLT 87 *10^3/uL
2024-08-05 PLT 100 *10^3/uL
2024-06-11 PLT 134 *10^3/uL
2024-03-04 PLT 173 *10^3/uL
2024-08-09 FKLC 27.37 mg/L *
2024-08-09 FLLC 18.28 mg/L
2024-08-09 FK/FL ratio 1.50 ratio
2024-03-13 IgG/A/M Kappa/Lambda No Paraprotein
2024-03-11 IgG (blood) 953 mg/dL
2024-03-11 IgA 102 mg/dL
2024-03-11 IgM 129.0 mg/dL
2024-03-05 IgE 6.64 IU/mL
[exam findings]
[MedRec]
[immunochemotherapy]
[addressing hypomagnesemia and elevated D-dimer levels]
Hypomagnesemia (1.5 mg/dL on 2024-08-21) is being treated with MgSO4 injections. Elevated D-dimer (2338 ng/mL) may warrant continued monitoring. Other lab results were generally unremarkable, and no medication issues were identified.
[exam findings]
[MedRec]
[consultation]
2024-08-21 Cardiology
2024-07-16
2024-07-09 Radiation Oncology
2024-07-09 Nephrology
2024-07-03 Family Medicine
[chemotherapy]
[managing hypokalemia and magnesium deficiency in renal potassium wasting]
Historical serum potassium levels indicate that the patient frequently experiences hypokalemia. In fact, urine data from 2024-07-08 showed potassium at 19.6 mmol/L and creatinine at 16.58 mg/dL, resulting in a urine K/Cr ratio as high as 118 mmol/g, which suggests renal potassium wasting.
The patient also has hypomagnesemia. Magnesium deficiency is often linked with hypokalemia, as literature suggests that magnesium deficiency exacerbates potassium wasting by increasing distal potassium secretion. A decrease in intracellular magnesium, due to magnesium deficiency, removes the magnesium-mediated inhibition of ROMK channels, leading to increased potassium secretion. However, magnesium deficiency alone does not necessarily cause hypokalemia; factors such as increased distal sodium delivery or elevated aldosterone levels may be required to worsen potassium wasting in the context of magnesium deficiency. Ref: Journal of the American Society of Nephrology 18(10):p 2649-2652, October 2007. DOI: 10.1681/ASN.2007070792
Increasing magnesium supplementation might help improve his hypokalemia.
2024-08-21 K (Potassium) 3.1 mmol/L
2024-08-08 K (Potassium) 3.3 mmol/L
2024-08-05 K (Potassium) 3.5 mmol/L
2024-08-03 K (Potassium) 3.0 mmol/L
2024-08-01 K (Potassium) 3.3 mmol/L
2024-08-01 K (Potassium) 3.6 mmol/L
2024-07-31 K (Potassium) 3.3 mmol/L
2024-07-30 K (Potassium) 3.4 mmol/L
2024-07-29 K (Potassium) 2.6 mmol/L
2024-08-21 Mg (Magnesium) 1.8 mg/dL
2024-08-08 Mg (Magnesium) 1.9 mg/dL
2024-08-05 Mg (Magnesium) 1.6 mg/dL
2024-08-03 Mg (Magnesium) 1.6 mg/dL
[AML treatment response: significant reduction in blast percentage]
Blast Percentage Trends: On 2024-06-11, the blast percentage was 87.0%, peaking at 93.3% on 2024-06-15, indicating an aggressive phase of AML. However, from 2024-07-16 to 2024-08-03, the blast percentage significantly decreased from 3.8% to 1.0%, suggesting a strong positive response to treatment.
Clinical Implications: The initial high blast percentage highlights active AML, while the subsequent decline indicates effective treatment and potential remission. Continuous monitoring is essential due to the risk of relapse.
[management of suspected acute pulmonary edema and cardiac dysfunction]
A CXR on 2024-08-20 indicated suspected acute pulmonary edema, and a cardiac echo on 2024-08-01 showed abnormal LV systolic function with global hypokinesia and pulmonary hypertension. If diuretics are used to manage this condition, a potassium-sparing diuretic would be a more appropriate choice given the patient’s renal potassium wasting.
[scheduled transfusions for managing pancytopenia, addressing elevated ALT with BaoGan]
Pancytopenia was noted, and a transfusion with 2 units of LPRBC and 2 units of LRP is scheduled. BaoGan (silymarin) has been prescribed for elevated ALT. No medication discrepancies were identified.
2024-07-30 WBC 1.47 x10^3/uL
2024-07-30 HGB 9.6 g/dL
2024-07-30 PLT 55 *10^3/uL
2024-07-30 ALT 109 U/L
2024-07-29 ALT 89 U/L
[exam findings]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
[diarrhea management and temporary neutropenia post-TPF treatment resolved]
The lowest neutrophil count within the past month was 1.82K/uL x 44% = 800/uL (grade 3), which occurred approximately one week after TPF administration (80% of the standard dose) on 2024-07-31. In fact, another session of TPF was given on the same day 2024-08-09. The data indicates that this neutropenia was a temporary condition, resolving to normal levels in days without the use of G-CSF.
Regarding diarrhea, it was not listed in the discharge diagnosis under service number I24072540, although loperamide was appropriately prescribed for this condition. No medication issues were identified.
2024-08-20 WBC 6.50 x10^3/uL
2024-08-16 WBC 4.70 x10^3/uL
2024-08-12 WBC 5.36 x10^3/uL
2024-08-09 WBC 1.82 x10^3/uL <-
2024-08-07 WBC 5.54 x10^3/uL
2024-07-30 WBC 4.24 x10^3/uL
2024-07-23 WBC 5.15 x10^3/uL
2024-07-20 WBC 3.96 x10^3/uL
2024-08-20 Neutrophil 68.6 %
2024-08-16 Neutrophil 64.6 %
2024-08-12 Neutrophil 67.3 %
2024-08-09 Neutrophil 43.9 % <-
2024-08-07 Neutrophil 74.8 %
2024-07-30 Neutrophil 71.6 %
2024-07-23 Neutrophil 71.7 %
2024-07-20 Neutrophil 61.9 %
On 2023-01-12, the PET scan showed no significant abnormal focal FDG uptake elsewhere except in the rectum with two regional lymph nodes and an old lesion in the left buccal region. The patient has been treated with TNT for rectal cancer. CCRT with FU was performed in February and March of 2023. The patient is currently being treated with the FOLFOX regimen.
According to PharmaCloud records, all recent medications were prescribed at our hospital and no medication reconciliation issues were identified.
[exam findings]
[surgical operation]
[chemotherapy]
[improving CINV control with aprepitant addition]
Due to chemotherapy-induced nausea and vomiting (CINV) documented on 2024-08-13, the FOLFOX dose was reduced to 80% during this hospitalization.
Since the initiation of FOLFOX, Aloxi (palonosetron) has been used to prevent CINV, but its effectiveness may be insufficient. It is recommended to add Emend (aprepitant) on days 1-3 (covered by NHI) to extend the prevention of CINV, allowing the full FOLFOX dose to be administered without compromising efficacy.
Additionally, CA-199 levels have shown a noticeable increase over the past month, which might warrant an investigation into possible changes in disease progression.
[oral akynzeo as an option for persistent CINV]
Oral Akynzeo (netupitant 300mg, palonosetron 0.5mg) is available in this hospital as a patient-paid option. It may be considered if CINV persists despite the addition of aprepitant.
[EPS treatments]
Acute extrapyramidal syndromes (EPS), such as dystonic reactions and akathisia, can treated with diphenhydramine (25 to 50 mg IV in adults, 30 mg was given as premedication with FOLFOX today). Benztropine (1 to 2 mg IV in adults, not available here) may be used initially, or if diphenhydramine therapy fails. Response is often dramatic and typically occurs within minutes of intravenous drug administration. Although the IV route is preferred, both diphenhydramine and benztropine may be given IM or orally. If initial treatment is successful, therapy is continued orally for two to three days to prevent recurrence.
Alternative treatments for EPS include benzodiazepines (eg, lorazepam 1 to 2 mg IV in adults, 1 mg IV at around 12:00 and 13:20 administered), amantadine (100 mg orally twice or three times daily in adults), or biperiden (2 mg orally in adults). At least two controlled studies have shown amantadine to be as effective as anticholinergic therapy, with fewer side effects. Propranolol (20 to 40 mg initial dose) reduces involuntary movements in akathisia, but does not reduce anxiety. A randomized trial of 13 patients with acute akathisia from antipsychotic medications reported a benefit from trazodone (100 mg/day orally in adults).
Ref: https://www.uptodate.com/contents/first-generation-typical-antipsychotic-medication-poisoning
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
[eGFR assessment and paclitaxel dosing]
Lab results from 2024-08-19 show an eGFR of 75.01 ml/min/1.73m², indicating no need for renal dose adjustment for paclitaxel. No issues with the current active medications were identified.
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
[Stable Vital Signs and Lab Results with Rising Tumor Markers]
Vital signs remained stable during this hospital stay, and lab results on 2024-08-20 were generally acceptable, with no medication discrepancies identified. However, both tumor markers CEA and CA199 have shown an upward trend, FOLFIRI has been initialized since 2024-08-02.
2024-08-13 CEA 9.21 ng/mL
2024-07-22 CEA (NM) 5.082 ng/mL
2024-04-03 CEA (NM) 2.018 ng/mL
2023-11-16 CEA 1.99 ng/mL
2024-08-13 CA199 54.44 U/mL
2023-11-16 CA199 28.03 U/mL
[reconciliation]
[optionally increase Norvasc to 1# daily]
According to PharmaCloud, this patient visited a local clinic for heartburn on 2023-05-03. However, the prescribed medication for a duration of 3 days is now expired. Currently, no issues with medication reconciliation have been identified.
Aside from anemia, the laboratory results from 2023-05-31 were largely within normal limits. There appears to be a downward trend in HGB levels in this patient following the initiation of FOLFOX treatments on 2023-03-09, with hemoglobin levels not fully recovering. This trend warrants continued monitoring.
[exam findings]
[MedRec]
The patient frequently complains of urinary tract infections, particularly when their blood sugar control is poor.
Allergy: NKA
PH: Type 2 DM since 2010, HTN, Dyslipidemia,
FH: grandma, grandpa, pa: DM, HTN
[lab data]
2024-08-20 HBsAg Nonreactive
2024-08-20 HBsAg Value 0.34 S/CO
2024-08-20 Anti-HCV Nonreactive
2024-08-20 Anti-HCV Value 0.12 S/CO
2024-08-20 Anti-HBc Reactive
2024-08-20 Anti-HBc Value 5.63 S/CO
[exam findings]
[MedRec]
[consultation]
[CT and MRI findings with PSA elevation and HBV management]
A CT scan on 2024-07-27 revealed a heterogeneous tumor (5.6 cm, showing progression) in the pelvic cavity with invasion into the left distal ureter, urinary bladder, and prostate. An MRI on 2024-05-21 showed a soft tissue lesion (3.5 cm) in the left pelvic cavity with a small cystic component and mass effect on the left lower ureter, raising suspicion of a neurogenic tumor. Elevated PSA and free PSA levels were also noted.
The Anti-HBc test on 2024-08-20 showed reactive. Antiviral prophylaxis is recommended to prevent hepatitis B reactivation if the patient is scheduled to receive anti-cancer therapy.
Other lab results showed generally acceptable blood counts, electrolytes, and liver and kidney function. No pathology report is available yet, and no medication issues were identified.
2024-08-20 PSA 17.702 ng/mL
2024-03-22 PSA 23.135 ng/mL
2024-08-20 Free PSA 3.780 ng/mL
2019-07-26 Free PSA 2.081 ng/mL
2018-05-18 Free PSA 1.732 ng/mL
[lab data]
2024-01-02 Anti-HBc (NM) Positive
2024-01-02 Anti-HBc Value (NM) 0.012
2024-01-02 Anti-HBs (NM) Positive
2024-01-02 Anti-HBs Value (NM) 12.6 mIU/mL
2024-01-02 HBsAg (NM) Negative
2024-01-02 HBsAg Value (NM) 0.477
2024-01-02 Anti-HCV (NM) Negative
2024-01-02 Anti-HCV Value (NM) 0.035
2023-12-27 Fe (Iron-bound) 36 ug/dL
2023-12-27 TIBC 276 ug/dL
2023-12-27 UIBC 240 ug/dL
[exam findings]
[MedRec]
[chemotherapy]
[CEA, CA199, and treatment assessment]
Lab results, including CEA and CA199 from 2024-08-19, were generally normal. Baraclude (entecavir) is being used to manage reactive Anti-HBc, and the patient is well-tolerated to the FOLFOX regimen. After reviewing the HIS5 and PharmaCloud databases, no medication discrepancies were identified.
The most recent CT scan was conducted on 2024-05-11. Given that it is now August, a follow-up CT might be beneficial for clinical management.
[exam findings]
[MedRec]
[consultation]
[managing elevated serum bilirubin and post-transfusion HGB monitoring]
Elevated serum bilirubin has been observed. Please ensure that bile flow remains unobstructed and monitor the post-transfusion rise in HGB levels. Additionally, supplementing sodium and albumin might also be considered.
2024-08-17 Na (Sodium) 131 mmol/L
2024-08-17 Albumin (BCG) 2.0 g/dL
2024-08-17 Bilirubin total 3.56 mg/dL
2024-07-30 Bilirubin total 0.81 mg/dL
2024-08-17 HGB 6.5 g/dL
2024-08-08 HGB 8.3 g/dL
[addressing daytime fatigue by modifying medication schedule]
I visited the patient late this morning. The patient was in bed while her husband rested on a nearby bench. The patient mentioned that her sleep quality has been poor recently due to frequent nighttime trips to the bathroom, which leaves her feeling very tired during the day.
Currently, Dulcolax (bisacodyl) is administered as HS. If the administration time is changed to earlier in the day, such as between lunch and dinner, it might help the patient to have bowel movements earlier before the bedtime. This adjustment could even make it possible to discontinue Zolon (zopiclone) HS, depending on the patient’s condition.
[elevated conjugated bilirubin: Uliden considered]
The primary contributor to the elevated total bilirubin appears to be conjugated bilirubin. Currently Buscopan (hyoscine-N-butylbromide) is in use since 2024-05-23.
If no contraindications are identified, adding Uliden (ursodeoxycholic acid 100mg) 1# BID or TID may be considered.
Maintaining bile flow throughout treatment is crucial to prevent biliary obstruction.
[elevated liver function tests and possible pancreatic cancer link]
Multiple liver function tests are elevated. It is unclear if this is related to the underlying pancreatic cancer.
The addition of BaoGan (silymarin) as a potential treatment option can be considered.
[lab data]
2024-07-31 Anti-HBc Nonreactive
2024-07-31 Anti-HBc Value 0.65 S/CO
2024-07-29 HBsAg Nonreactive
2024-07-29 HBsAg Value 0.34 S/CO
2024-07-29 Anti-HBs 16.65 mIU/mL
2024-07-29 Anti-HCV Nonreactive
2024-07-29 Anti-HCV Value 0.16 S/CO
[exam findings]
[MedRec]
[chemotherapy]
Obinutuzumab: Drug information - 2024-08-19 - https://www.uptodate.com/contents/obinutuzumab-drug-information
Chlorambucil: Drug information - 2024-08-19 - https://www.uptodate.com/contents/chlorambucil-drug-information
[scheduling obinutuzumab and chlorambucil for CLL treatment; HBV risk assessment]
Gazyva (obinutuzumab) for previously untreated chronic lymphocytic leukemia is administered in combination with chlorambucil. For Cycle 1: IV administration includes 100 mg on day 1, followed by 900 mg on day 2, and 1,000 mg weekly for 2 doses (days 8 and 15) within a 28-day treatment cycle. Since the treatment started on 2024-08-14 (day 1), the next two administrations should be scheduled for 2024-08-21 and 2024-08-28.
Anti-HBs is 16.65 mIU/mL and Anti-HBc is nonreactive, indicating that the patient has been vaccinated for HBV. The risk of HBV reactivation is relatively low, so prophylactic use of Baraclude or Vemlidy might not be necessary.
Leukeran (chlorambucil 2mg/tab, KLEUK) 7# BID was administered on 2024-08-14, totaling 28 mg that day. With a body weight of 55 kg, this dosage equates to approximately 0.5 mg/kg. The schedule for combined use with obinutuzumab should follow administration on day 1 and day 15 of each 28-day cycle, so the next chlorambucil dose is due on 2024-08-28.
Before administering chlorambucil, the patient still had certain WBC, HGB, and PLT counts, indicating no signs of bone marrow failure, so the medication can be administered.
All oral medications currently used are suitable for administration via feeding tube. No medication discrepancies were identified.
2024-08-19 WBC 1.10 x10^3/uL
2024-08-15 WBC 57.65 x10^3/uL
2024-08-15 WBC 30.39 x10^3/uL
2024-08-12 WBC 4.70 x10^3/uL
2024-08-19 HGB 7.9 g/dL
2024-08-15 HGB 7.2 g/dL
2024-08-15 HGB 7.8 g/dL
2024-08-12 HGB 8.8 g/dL
2024-08-19 PLT 8 *10^3/uL
2024-08-15 PLT 120 *10^3/uL
2024-08-15 PLT 17 *10^3/uL
2024-08-12 PLT 22 *10^3/uL
[exam findings]
[MedRec]
[immunochemotherapy]
[lab data]
2024-06-15 Anti-HBs 312.09 mIU/mL
2024-06-15 Anti-HBc Reactive
2024-06-15 Anti-HBc Value 5.67 S/CO
2024-06-15 Anti-HCV Nonreactive
2024-06-15 Anti-HCV Value 0.11 S/CO
2024-06-15 HBsAg Nonreactive
2024-06-15 HBsAg Value 0.32 S/CO
[exam findings]
[MedRec]
[chemotherapy]
[effective management post-doxorubicin and ifosfamide session]
Lab results on 2024-08-16 were generally normal, and vital signs have remained stable in recent days, even after this session of doxorubicin and ifosfamide. Baraclude (entecavir) is being used for reactive Anti-HBc (2024-06-15). No medication discrepancies were identified.
[exam findings]
[chemotherapy]
2024-08-19 - vincristine sulfate 2mg NS 100mL 10min
2024-08-15 - cytarabine 40mg IT 3min + methylprednisolone 40mg XX 3min
2024-08-14 - methotrexate 15mg IT 3min
2024-08-12 - vincristine sulfate 2mg NS 100mL 10min
[pancytopenia management during combination therapy]
Glivec (imatinib 100mg) 4# BID has been administered in combination with vincristine, cytarabine, and methylprednisolone since 2024-08-12. Pancytopenia has developed since then; however, anemia and thrombocytopenia were observed prior to treatment, so the therapy should not be considered the sole cause of the low blood cell counts.
Blood transfusion was performed on 2024-08-17 and G-CSF (filgrastim) 300mg SC daily was initiated today, and no issues have been identified.
2024-08-19 WBC 1.35 x10^3/uL
2024-08-17 WBC 3.11 x10^3/uL
2024-08-15 WBC 3.36 x10^3/uL
2024-08-14 WBC 13.88 x10^3/uL
2024-08-12 WBC 147.07 x10^3/uL
2024-08-10 WBC 163.98 x10^3/uL
2024-08-08 WBC 200.62 x10^3/uL
2024-08-19 Blast 7.2 %
2024-08-17 Blast 7.2 %
2024-08-15 Blast 53.0 %
2024-08-14 Blast 81.6 %
2024-08-12 Blast 68.0 %
2024-08-10 Blast 89.0 %
2024-08-08 Blast 98.0 %
2024-08-19 HGB 6.4 g/dL
2024-08-17 HGB 8.1 g/dL
2024-08-15 HGB 8.8 g/dL
2024-08-14 HGB 11.0 g/dL
2024-08-12 HGB 9.6 g/dL
2024-08-10 HGB 9.0 g/dL
2024-08-08 HGB 8.3 g/dL
2024-08-19 PLT 26 *10^3/uL
2024-08-17 PLT 51 *10^3/uL
2024-08-15 PLT 59 *10^3/uL
2024-08-14 PLT 16 *10^3/uL
2024-08-12 PLT 32 *10^3/uL
2024-08-10 PLT 44 *10^3/uL
2024-08-08 PLT 24 *10^3/uL
[exam findings]
[MedRec]
[chemotherapy]
….-..-..
2024-03-28 - leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr (CCRT)
2024-03-07 - leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr (CCRT)
2024-02-22 - leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr (CCRT)
2024-02-01 - leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr (CCRT)
2024-01-24 - leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr (CCRT)
2024-01-16 - leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr (CCRT)
[Managing Possible Infection and Normocytic Anemia]
CRP is elevated at 7.5 mg/dL with an increased WBC count, indicating a possible infection; Cravit (levofloxacin) is currently being used.
Normocytic anemia has also been observed; however, given that MCV has remained over 90 fL for months, iron deficiency is less likely (she is taking Foliromin currently). Recent ferritin and/or transferrin saturation test results are not available and might be considered.
[exam findings]
[chemotherapy]
[exam findings]
[MedRec]
[immunochemotherapy]
Systemic treatment for HER2-positive metastatic breast cancer - https://www.uptodate.com/contents/systemic-treatment-for-her2-positive-metastatic-breast-cancer
Pertuzumab, trastuzumab, and docetaxel for HER2-positive metastatic breast cancer - 2024-08-15 - https://www.uptodate.com/contents/image?imageKey=ONC%2F96342
[clearance for DHP treatment without dose adjustment]
The patient is scheduled to receive DHP (docetaxel, trastuzumab, pertuzumab) treatment. Based on the blood cell count, electrolytes, liver, and renal function lab results from 2024-08-14, there are no contraindications, and no dose adjustments are necessary.
(pertuzumab loading was missed)
[exam findings]
[MedRec]
[chemotherapy]
[proceeding with chemotherapy despite mild neutropenia and normocytic anemia]
Mild neutropenia and normocytic anemia were observed; however, since the ANC is > 1500/uL, this does not preclude proceeding with chemotherapy. Other lab results were generally normal, and no medication discrepancies were identified.
2024-08-13 WBC 3.03 x10^3/uL
2024-08-13 Neutrophil 61.3 %
2024-08-13 HGB 9.8 g/dL
2024-08-13 MCV 90.9 fL
[exam findings]
[MedRec]
[surgical operation]
[review of pain management and symptom relief medications]
According to the PharmaCloud prescription records, this patient has primarily been treated at NTUH, with medications including fentanyl, oxycodone, naproxen, diphenhydramine, and hydrocortisone for pain management and symptom relief.
On 2024-08-13, the CRP was 12.4 mg/dL, and a urine exam showed bacteria 1+. The patient is currently using Soonmelt (amoxicillin, clavulanic acid) and morphine. No issues with the current medication regimen were identified.
[lab data]
2024-03-30 Anti-HBc Nonreactive
2024-03-30 Anti-HBc Value 0.10 S/CO
2024-03-30 Anti-HBs 6.47 mIU/mL
2024-03-30 Anti-HCV Nonreactive
2024-03-30 Anti-HCV Value 0.08 S/CO
2024-03-30 HBsAg Nonreactive
2024-03-30 HBsAg Value 0.54 S/CO
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
[managing hypomagnesemia, weight loss, and anemia]
Hypomagnesemia (Mg 1.6 mg/dL on 2024-08-12) is currently being treated with injectable MgSO4.
The patient’s body weight decreased from 37.9 kg on 2024-04-12 to 31 kg on 2024-08-12, a nearly 20% loss in 4 months. Megest (megestrol) has been added, but if weight loss continues, additional nutritional interventions may be necessary.
Lab results from 2024-08-12 also showed HGB 10.0 g/dL and MCV 79.5 fL, indicating microcytic anemia, suggesting that some iron supplementation could be beneficial.
[effectiveness of FOLFOX regimen under scrutiny]
The treatment regimen was shifted from FOLFIRI to FOLFOX following CT and MRI scans in late May that showed disease progression. No new CT or MRI scans have been conducted since then. However, both CEA and CA199 levels have shown a significant upward trend, suggesting that the new regimen may be less effective than expected.
2024-07-16 CEA 38.49 ng/mL
2024-06-04 CEA 18.95 ng/mL
2024-05-22 CEA 20.73 ng/mL
2024-04-25 CEA 14.20 ng/mL
2024-07-16 CA199 294.03 U/mL
2024-06-04 CA199 201.21 U/mL
2024-05-22 CA199 183.95 U/mL
2024-04-25 CA199 129.01 U/mL
[elevated tumor markers amidst normal lab results; Avastin + FOLFIRI administration deemed appropriate]
With the exception of elevated tumor markers CEA at 27 ng/mL and CA199 at 224 U/mL, lab results from 2024-03-27 were largely within normal parameters. Given these findings, the administration of Avastin + FOLFIRI on 2024-03-29 appears to be medically appropriate without contraindications based on the lab data. Additionally, a review of the medication records revealed no discrepancies.
[MedRec]
[consultation]
2024-03-19 Rehabilitation
2024-03-15 Nephrology
2024-03-14
2024-03-05
2024-03-04
2024-02-22
2024-02-07 Thoracic Surgery
2024-01-31 Rehabilitation
2024-01-30 Ear Nose Throat
[chemotherapy]
[PLT count stabilized after LRP transfusion]
After transfusion of 2 units of LRP, the platelet count has risen to nearly 100K/uL, significantly reducing the immediate risk of severe bleeding.
The elevated bilirubin levels are trending closer to the normal range. A CT-guided biopsy of the right lung mass is scheduled for tomorrow 2024-06-14. No medication-related issues have been identified at this time.
2024-06-12 Bilirubin total 1.26 mg/dL
2024-05-24 Bilirubin total 1.48 mg/dL
2024-05-06 Bilirubin total 1.84 mg/dL
2024-04-18 Bilirubin total 2.46 mg/dL
2024-06-12 Bilirubin direct 0.43 mg/dL
2024-05-24 Bilirubin direct 0.48 mg/dL
2024-05-06 Bilirubin direct 0.59 mg/dL
2024-04-18 Bilirubin direct 0.72 mg/dL
[cisplatin & AKI: slow rise in creatinine after 5-7 Days, urinary concentration defect]
Acute kidney injury (AKI) from cisplatin exposure typically manifests with a slow rise in serum creatinine after five to seven days of therapy. The timing of AKI may be earlier (within three to five days of therapy) in patients with comorbid risk factors, such as preexisting chronic kidney disease (CKD), older age, hypoalbuminemia, or concomitant nephrotoxic drugs.
2024-03-15 Creatinine 3.93 mg/dL
2024-03-14 Creatinine 2.65 mg/dL
2024-03-11 Creatinine 0.99 mg/dL
2024-03-08 Creatinine 0.87 mg/dL
2024-03-06 Creatinine 0.83 mg/dL
2024-03-15 eGFR 16.43 ml/min/1.73m^2
2024-03-14 eGFR 25.89 ml/min/1.73m^2
2024-03-11 eGFR 80.64 ml/min/1.73m^2
2024-03-08 eGFR 93.60 ml/min/1.73m^2
2024-03-06 eGFR 98.83 ml/min/1.73m^2
2024-03-15 BUN 125 mg/dL
2024-03-14 BUN 89 mg/dL
2024-03-11 BUN 36 mg/dL
2024-03-08 BUN 21 mg/dL
Most patients will experience a mild to moderate increase in serum creatinine (ie, 1.5 to 2.9 times baseline), while some may progress to more severe AKI (serum creatinine > 3 times baseline) or require kidney replacement therapy. Severe AKI is uncommon in the absence of preexisting CKD and/or other comorbid risk factors.
Unless the kidney injury is severe, the urine output in patients with cisplatin nephrotoxicity typically remains above 1000 mL per day due to the induction of a concentrating defect. This defect may reflect platinum-induced damage to the loop of Henle, where the countercurrent gradient required for urinary concentration is established, or to the collecting tubules, the site of action of antidiuretic hormone.
[sepsis concern: left shift, elevated markers & BUN/Cr, AKI]
Lab findings consistent with sepsis include left-shifted WBC DC, elevated PCT and CRP, and elevated BUN/Creatinine (>31).
2024-03-15 Band 11.5 %
2024-03-15 Neutrophil 56.7 %
2024-03-15 Lymphocyte 12.5 %
2024-03-15 Metamyelocyte 8.7 %
2024-03-15 Myelocyte 1.9 %
2024-03-15 CRP 13.6 mg/dL
2024-03-15 Procalcitonin (PCT) 3.73 ng/mL
This presentation raises concern for sepsis-associated AKI with possible vasodilation.
[loperamide treatment for 5-FU-induced diarrhea]
Treatment with CDDP and 5-FU was initiated on 2024-03-08. It is subsequently reported diarrhea. While the TPR panel recorded bowel movements of 0 to 2 times per day between 2024-03-07 to 2024-03-13, a progress note documented > 10 bowel movements on 2024-03-13.
UpToDate Drug Information indicates that cisplatin is associated with a less than 1% incidence of diarrhea, whereas fluorouracil is known to cause severe diarrhea. Based on this information, it is more likely that fluorouracil is the primary cause of the diarrhea.
Loperamide has been initiated as the appropriate treatment for this type of diarrhea.
[exam findings]
[MedRec]
[consultation]
4/21 4/22 4/23 4/44[immunochemotherapy]
[Monitoring WBC Levels Post R-CHOP Regimen]
The final session of the R-CHOP regimen was administered on 2024-07-23, with the WBC nadir observed on 2024-08-02, approximately 10 days later. Granocyte (lenograstim 250ug) was administered from 2024-07-31 to 2024-08-08. Currently, there is no evidence of neutropenia.
[hyperuricemia managed with febuxostat, preventing HBV activation with tenofovir]
Beta-2 microglobulin levels remain elevated. Hyperuricemia is currently managed with Feburic (febuxostat), and Vemlidy (tenofovir alafenamide) is used to prevent HBV reactivation. Blood sugar control is acceptable. No medication discrepancies were identified.
2024-06-15 Uric Acid 7.8 mg/dL
2024-06-12 B2-Microglobulin 7071 ng/mL
2024-05-10 B2-Microglobulin 6101 ng/mL
2024-04-08 B2-Microglobulin 7052 ng/mL
The neutropenia that developed following the administration of the R-COP regimen has now resolved.
[hypercalcemia resolved: Miacalcic - discontinuation option]
The serum calcium level has already decreased to within the normal range (albumin also in normal range). If the cause of the hypercalcemia is no longer present, Miacalcic (calcitonin) can be discontinued.
[improving kidney function & low K]
Based on the data, the patient’s kidney function is improving.
2024-03-12 Creatinine 3.88 mg/dL
2024-03-11 Creatinine 4.14 mg/dL
2024-03-09 Creatinine 4.28 mg/dL
2024-03-12 BUN 64 mg/dL
2024-03-11 BUN 67 mg/dL
2024-03-09 BUN 71 mg/dL
Serum potassium levels have fallen below the reference range, possibly due to the use of furosemide. Const-K is currently used for potassium supplementation.
Once kidney function (eGFR) has recovered to above 30 and is expected to continue improving, spironolactone can be added as an aldosterone antagonist to partially replace furosemide to maintain serum potassium levels within a reasonable range. One of the methods that is used is spironolactone 50 mg and furosemide 20 mg 2 doses daily..
[dosing strategies for calcitonin in hypercalcemic emergencies]
Calcitonin can be utilized as an adjunctive treatment for severe hypercalcemia:
It is recommended for use in conjunction with other suitable agents (such as IV hydration and bisphosphonates) for patients experiencing severe hypercalcemia (for example, symptomatic cases with an albumin-corrected serum calcium level exceeding 14 mg/dL [>3.5 mmol/L]). This is to promptly decrease serum calcium levels, while bisphosphonate therapy achieves a sustained effect.
For IM or SUBQ administration: The initial dose is 4 units/kg every 12 hours. Should the reduction in calcium prove insufficient after 6 to 12 hours, the dosage may be escalated to 8 units/kg every 6 to 12 hours. It is advisable to limit the total duration of therapy to between 24 to 48 hours due to the risk of tachyphylaxis.
[weighing denosumab for hypercalcemia with renal considerations]
Isotonic saline hydration and loop diuretics are currently being used to treat hypercalcemia.
Renal lab results:
Given the patient’s compromised renal function, the use of bisphosphonates, which have an onset of action ranging from 24 to 72 hours and a duration of action between 2 to 4 weeks, is not feasible.
Denosumab, with an onset of action between 4 to 10 days and a duration of action extending from 4 to 15 weeks, may be a viable alternative considering the risk of tachyphylaxis associated with calcitonin. If there are no clinical contraindications, denosumab at a dosage of 120 mg once weekly for up to three doses could be contemplated.
[Regpara for hypercalcemia]
Regpara (cinacalcet 25mg/tab, available in this hospital now; onset of action 2-3 days) belongs to a drug class called calcimimetics. It works by mimicking the effect of calcium on calcium-sensing receptors. This action helps to lower parathyroid hormone (PTH) levels. Regpara is used to treat hypercalcemia caused by conditions like parathyroid carcinoma or secondary hyperparathyroidism in patients with CKD.
Initial 25 mg twice daily; may increase dose incrementally (to 50 mg twice daily, 75 mg twice daily, and 100 mg 3 to 4 times daily) every 2 to 4 weeks as necessary to normalize serum calcium levels.
[exam findings] (not completed)
[chemotherapy]
trabectedin - 2024-08-12 - https://www.uptodate.com/contents/trabectedin-drug-information
[exam findings]
[chemotherapy]
[carbapenem safety in penicillin-allergic patients: Tapimycin (piperacillin, tazobactam) and Mepem (meropenem) cross-reactivity]
Studies have shown that the risk of cross-reactivity between penicillins and carbapenems is relatively low. According to a systematic review and meta-analysis published in the Journal of Allergy and Clinical Immunology: In Practice, the risk of cross-reactivity to any carbapenem in penicillin-allergic patients is around 0.87% (95% CI, 0.32-2.32%) (https://pubmed.ncbi.nlm.nih.gov/31170539/). This suggests that many patients with a penicillin allergy can safely use carbapenems like meropenem, although careful consideration and possible consultation with an allergist are recommended.
Another study demonstrates that bedside meropenem allergy testing for hospitalized patients with reported penicillin allergies is safe and effective, with 96.4% of patients tolerating the procedure and only two experiencing non-severe reactions. This approach allows for the appropriate use of meropenem, avoiding less effective second-line antibiotics. Overall, the procedure enhances patient care and helps mitigate antibiotic resistance. (https://doi.org/10.1016/j.alit.2023.02.008)
[lab data]
[exam findings] (not completed)
[chemotherapy]
[patient tolerates FOLFOX regimen well with grossly normal lab results]
Lab data on 2024-07-30 were generally normal, and the patient is well tolerated with the FOLFOX regimen. Baraclude (entecavir) has been properly administered for positive Anti-HBc (2024-01-09). No medication issues were found.
[exam findings]
[MedRec]
[chemotherapy]
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
[Nexium (esomeprazole) tube feeding]
To prepare Nexium (esomeprazole) for administration through a feeding tube, use the Simple Suspension Method (SSM). The SSM involves administering tablets or capsules by disintegrating and suspending them in warm water without crushing or opening the capsule. This method allows the medication to be converted into a liquid form suitable for feeding tube administration.
[considering silimarin for (Brosym-induced?) hepatic enzyme elevation]
General urine examination:
The urine exam indicated a suspected infection. After Brosym (cefoperazone, sulbactam) was initiated on 2024-07-01, the patient’s body temperature has begun to decrease. Records show the patient has tachycardia, while respiratory rate and blood pressure remain stable, with an SpO2 of 95%.
Possible adverse reactions to Brosym include increased serum alanine aminotransferase and increased serum aspartate aminotransferase. It is unclear whether the elevation in hepatic enzymes occurred after starting Brosym, so continued monitoring is necessary. The addition of BaoGan (silymarin) might be beneficial.
2024-07-01 AST 91 U/L
2024-06-20 AST 35 U/L
2024-07-01 ALT 69 U/L
2024-06-20 ALT 18 U/L
[managing calcium oxalate crystals in urine]
The urine exam (2024-07-01) revealed calcium oxalate crystals. If this result is expected to cause problems, the medical management can aim to reduce urinary calcium oxalate saturation and oxalate production to minimize kidney oxalate deposition and delay the progression of kidney injury.
[MedRec]
[managing pancytopenia with frequent blood transfusions]
Pancytopenia and a right-shifted WBC differential count were observed. Elevated CRP levels and normal PCT levels might suggest a viral infection or non-infectious inflammatory conditions.
The patient frequently receives blood products, so checking iron levels might be advisable.
2024-07-29 Procalcitonin (PCT) 0.09 ng/mL
2024-07-29 CRP 5.6 mg/dL
2024-07-29 Band 0.0 %
2024-07-29 Neutrophil 39.2 %
2024-07-29 Lymphocyte 41.2 %
2024-07-29 Monocyte 4.9 %
2024-07-29 Eosinophil 4.9 %
2024-07-29 Basophil 1.0 %
2024-07-29 Metamyelocyte 7.8 %
2024-07-29 Blast 1.0 %
2024-07-29 Atypical Lymphocyte 0.0 %
2024-07-29 Reticulocyte Ratio 2.250 %
2024-07-29 WBC 2.49 x10^3/uL
2024-07-29 HGB 7.5 g/dL
2024-07-29 PLT 22 *10^3/uL
[exam findings]
[MedRec]
[consultation]
[immunochemotherapy]
[managing high alt, ast, and bilirubin levels]
ALT, AST, and bilirubin levels remain elevated. BaoGan (silymarin) and Uliden (ursodeoxycholic acid) are being used, and no medication discrepancies have been identified.
2024-07-29 ALT 122 U/L
2024-07-10 ALT 126 U/L
2024-06-25 ALT 154 U/L
2024-07-29 AST 129 U/L
2024-07-10 AST 108 U/L
2024-06-25 AST 132 U/L
2024-07-29 Bilirubin direct 0.60 mg/dL
2024-06-25 Bilirubin direct 0.44 mg/dL
2024-06-04 Bilirubin direct 0.50 mg/dL
[the current treatment regimen is not suspected to be the primary contributor to the patient’s established liver impairment]
The patient’s liver function tests have shown persistent abnormalities for several months, characterized by elevated levels of AST, ALT, and bilirubin. Notably, these abnormalities predate the initiation of the current Erbitux (cetuximab) plus FOLFOX regimen in Dec 2023. Therefore, a causal relationship between the treatment and the current liver impairment is not absolute likely.
[liver impairment history might not be current regimen related]
The patient’s liver function has remained abnormal for the past months, as indicated by consistently elevated AST, ALT, and bilirubin levels. The current regimen of Erbitux (cetuximab) plus FOLFOX was initiated in Dec 2023, while the elevated liver function test results occurred well before the regimen started. Therefore, it cannot be directly concluded that the regimen is the primary cause of the recent liver impairment.
2024-05-14 AST 125 U/L
2024-04-15 AST 110 U/L
2024-04-03 AST 113 U/L
2024-03-20 AST 131 U/L
2024-03-06 AST 138 U/L
2024-02-19 AST 138 U/L
2024-02-07 AST 155 U/L
2024-01-30 AST 134 U/L
2024-01-10 AST 148 U/L
2024-01-02 AST 104 U/L
2024-05-14 ALT 126 U/L
2024-04-15 ALT 111 U/L
2024-04-03 ALT 146 U/L
2024-03-20 ALT 148 U/L
2024-03-06 ALT 173 U/L
2024-02-19 ALT 174 U/L
2024-02-07 ALT 222 U/L
2024-01-30 ALT 172 U/L
2024-01-28 ALT 192 U/L
2024-01-10 ALT 208 U/L
2024-01-02 ALT 155 U/L
2024-05-14 Bilirubin direct 0.45 mg/dL
2024-04-15 Bilirubin direct 0.53 mg/dL
2024-03-20 Bilirubin direct 0.54 mg/dL
2024-02-19 Bilirubin direct 0.39 mg/dL
2024-01-30 Bilirubin direct 0.64 mg/dL
2024-01-02 Bilirubin direct 0.69 mg/dL
[updated imaging and further tests advised due to rising tumor markers]
The most recent imaging study was performed on 2024-02-21. Tumor markers CEA and CA199 showed signs of rising from their lowest levels. It might be advisable to update the medical imaging and/or obtain new marker readings through a blood draw.
2024-04-12 CEA (NM) 24.598 ng/ml
2024-03-12 CEA (NM) 23.991 ng/ml
2024-02-16 CEA (NM) 85.185 ng/ml
2024-04-12 CA-199 (NM) 1971.020 U/ml
2024-03-12 CA-199 (NM) 1451.260 U/ml
2024-02-16 CA-199 (NM) 7879.800 U/ml
[considering Uliden for bilirubin management and potential Baraclude dosage adjustment]
Given that the increase in bilirubin is primarily due to direct bilirubin, and considering the persistently high total bilirubin, adding Uliden (ursodeoxycholic acid 100 mg) at a dose of 1# QD might be an optional treatment to improve this condition.
Should HBV DNA PCR and HBeAb also be tested to determine if Baraclude (entecavir) should be increased from 0.5 mg to 1 mg?
[Avastin to Erbitux + FOLFOX: markers change support CT’s partial response]
The patient’s treatment regimen transitioned from Avastin + FOLFOX (last used in Nov 2023) to Erbitux + FOLFOX in Dec 2023. A CT scan comparison on 2024-02-21, showed findings consistent with the partial response observed on the prior CT scan from 2023-11-10.
Furthermore, these imaging results correlate well with the ongoing decline in CEA and CA199 tumor markers over the past 3 months. No medication issues found.
2024-03-12 CEA (NM) 23.991 ng/ml
2024-02-16 CEA (NM) 85.185 ng/ml
2024-01-16 CEA (NM) 211.760 ng/ml
2023-12-26 CEA (NM) 433.020 ng/ml
2023-11-28 CEA (NM) 737.500 ng/ml
2024-03-12 CA-199 (NM) 1451.260 U/ml
2024-02-16 CA-199 (NM) 7879.800 U/ml
2024-01-16 CA-199 (NM) 12838.000 U/ml
2023-12-26 CA-199 (NM) 19957.500 U/ml
2023-11-28 CA-199 (NM) 17565.000 U/ml
LFTs remained elevated, BaoGan is currently being used. Other labs were largely unremarkable.
No medication discrepancy found.
[high direct-to-total bilirubin ratio]
Lab data:
The ratio of direct bilirubin to total bilirubin showed an upward trend in the serial lab data. Normally, the ratio is less than 20%. A high ratio suggests a problem with the conjugation or excretion of bilirubin. Possible causes of a high ratio:
If primary biliary cholangitis is identified, the addition of Ursodiol (ursodeoxycholic acid) might be a treatment option.
[cetuximab toxicity: dose adjustment strategies]
Following the CT scan on 2023-11-10, which revealed multiple liver metastases indicating progressive disease, the treatment plan was altered from Avastin + FOLFOX to Erbitux + FOLFOX. The patient was admitted to receive the second session of the Erbitux + FOLFOX regimen.
Due to elevated levels of DBI, TBI, AST, ALT, and alkaline phosphatase, a reduced dose of the regimen was administered. Tumor markers CEA and CA199 continue to be elevated, and a significant downward trend has not been observed.
Our dermatologist has been consulted regarding the management of dermatologic toxicity and infectious sequelae associated with cetuximab, such as acneiform rash and mucocutaneous disease. The recommended approach for managing these side effects is as follows:
The refill of Baraclude (entecavir) prescribed by our gastroenterologist is included in the list of active medications with no discrepancy found.
A 28-day supply of Baraclude (entecavir) refilled on 2023-07-25 has been added as a current use item and no medication reconciliation issues found.
[liver function follow-up]
Observation shows a spike in liver enzymes, which exceeded 200 U/L in early June. Despite a visible decrease, the levels have not yet returned to the normal range. The patient is currently prescribed BaoGan (silymarin). At this time, there does not appear to be a need to change the treatment plan. Please continue to monitor the changes closely.
2023-07-26 S-GPT/ALT 97 U/L 2023-07-13 S-GPT/ALT 155 U/L 2023-07-07 S-GPT/ALT 101 U/L 2023-06-25 S-GPT/ALT 140 U/L 2023-06-21 S-GPT/ALT 156 U/L 2023-06-14 S-GPT/ALT 179 U/L 2023-06-10 S-GPT/ALT 235 U/L 2023-06-09 S-GPT/ALT 217 U/L 2023-04-26 S-GPT/ALT 27 U/L 2023-04-14 S-GPT/ALT 25 U/L
[exam findings]
[MedRec]
[immunochemotherapy]
[exam findings]
[consultation]
[surgical operation]
[chemotherapy]
[liver function remains abnormal]
Liver function tests continue to show elevated levels, indicating that the liver is still under stress, even with silymarin treatment. Regular monitoring is necessary.
[rising cea levels since august 2023, elevated liver enzymes in june 2024]
It appears that CEA levels reached their lowest point in Aug 2023 and have since been gradually rising. Additionally, liver enzymes ALT and AST have shown a noticeable increase compared to the previous month. BaoGan has been prescribed and will also be provided upon discharge. No medication discrepancies were identified.
2024-04-30 CEA (NM) 7.236 ng/ml
2024-03-15 CEA (NM) 6.671 ng/ml
2024-02-02 CEA (NM) 6.639 ng/ml
2023-08-29 CEA (NM) 4.708 ng/ml
2023-07-04 CEA (NM) 7.161 ng/ml
2022-12-29 CEA (NM) 31.350 ng/ml
2022-09-23 CEA (NM) 34.242 ng/ml
2022-07-05 CEA (NM) 360.500 ng/ml
2024-06-24 ALT 80 U/L
2024-06-03 ALT 85 U/L
2024-04-28 ALT 52 U/L
2024-04-15 ALT 53 U/L
2024-03-13 ALT 58 U/L
2024-01-29 ALT 59 U/L
2023-12-10 ALT 43 U/L
2023-11-13 ALT 34 U/L
2024-06-24 AST 51 U/L
2024-06-03 AST 49 U/L
2024-04-28 AST 30 U/L
2024-04-15 AST 36 U/L
2024-03-13 AST 36 U/L
2024-01-29 AST 37 U/L
2023-12-10 AST 35 U/L
2023-11-13 AST 31 U/L
[exam findings]
[MedRec]
[ongoing treatment and monitoring for Ibrance and Femara regimen for managing neutropenia]
The patient has been taking Ibrance (palbociclib 75mg) and Femara (letrozole 2.5mg) daily for several months. While the latter is at the recommended dose, the standard dose for Ibrance is 125mg once daily for 21 days followed by 7 days off, repeated every 28 days. However, the actual palbociclib administration has been 75mg once daily for 14 or even 7 days, followed by 7 days off.
The patient has experienced neutropenia multiple times, with WBC counts not exceeding 3K/uL in recent months. Despite this, further dose reduction or interval increase for palbociclib is not recommended as it is already at the minimum recommended dose and administered less frequently.
Another reason for not adjusting the Ibrance dose or frequency is that tumor markers CA153 and CEA continue to decline, and imaging (MRI on 2024-07-05 and CT on 2024-04-08) showed that the disease remains controlled, indicating the current regimen is still effective.
If there is concern about the prolonged low WBC count leading to infection, the use of G-CSF might be considered.
2024-07-12 CA-153 66.283 U/ml
2024-04-12 CA-153 112.348 U/ml
2024-01-03 CA-153 107.046 U/ml
2023-10-09 CA-153 158.890 U/ml
2023-07-07 CA-153 234.040 U/ml
2024-07-12 CEA 4.785 ng/ml
2024-04-12 CEA 7.688 ng/ml
2024-01-03 CEA 10.442 ng/ml
2023-10-09 CEA 12.856 ng/ml
2023-07-07 CEA 36.463 ng/ml
2024-07-26 WBC 1.78 x10^3/uL **
2024-07-05 WBC 1.86 x10^3/uL **
2024-06-06 WBC 2.17 x10^3/uL *
2024-05-22 WBC 1.69 x10^3/uL **
2024-05-15 WBC 1.63 x10^3/uL **
2024-04-26 WBC 2.65 x10^3/uL *
2024-04-08 WBC 2.25 x10^3/uL *
2024-03-19 WBC 2.93 x10^3/uL *
2024-02-19 WBC 3.20 x10^3/uL
2024-01-22 WBC 2.91 x10^3/uL *
2023-12-27 WBC 1.86 x10^3/uL **
2023-12-06 WBC 3.08 x10^3/uL
2023-11-08 WBC 2.62 x10^3/uL *
2023-10-04 WBC 1.90 x10^3/uL **
2023-09-13 WBC 2.48 x10^3/uL *
2023-08-16 WBC 4.59 x10^3/uL
2023-08-12 WBC 3.08 x10^3/uL
2023-08-11 WBC 2.53 x10^3/uL *
2023-08-09 WBC 1.36 x10^3/uL **
2023-08-07 WBC 1.83 x10^3/uL **
2023-07-31 WBC 2.33 x10^3/uL *
2023-07-03 WBC 6.85 x10^3/uL
[leukopenia]
The patient’s primary medications include the cyclin-dependent kinase inhibitor palbociclib and the aromatase inhibitor letrozole. Palbociclib was initially prescribed at a daily dose of 125mg starting from late July this year, which was then reduced to 75mg daily from early August. Letrozole has been consistently administered at a daily dose of 2.5mg. The bone mineral density loss associated with the use of AI letrozole and bone metastases are being managed with zoledronic acid and calcium supplements.
Neutropenia, including grades 3 and 4, is a common observation in patients taking palbociclib. The median duration of neutropenia of grade >=3 is approximately 7 days. Cases of febrile neutropenia and neutropenic sepsis have also been reported. Neutropenia caused by palbociclib is rapidly reversible upon stopping the medication.
Our hospital currently stocks Ibrance (palbociclib) in 125mg, 100mg, and 75mg dosages. However, the patient is already on the lowest recommended dose of 75mg. Other CDK4/6 inhibitors like abemaciclib and ribociclib also have similar adverse effects of leukopenia.
According to the latest NCCN guidelines, for postmenopausal patients with ER (+), PR (+), Her2 (-) stage IV breast cancer, the recommended treatments include:
Both options involve the use of a CDK4/6 inhibitor. Given that the CT scan on 2023-12-27 showed disease regression, indicating that the current regimen is still effective in controlling the disease.
While some research suggests that G-CSF isn’t always necessary for managing neutropenia in CDK4/6 inhibitor-based treatments, it’s important to consider the differences between this and chemotherapy-induced neutropenia. Ref: Management of adverse events during cyclin-dependent kinase 4/6 (CDK4/6) inhibitor-based treatment in breast cancer. Ther Adv Med Oncol. 2018 Sep 3;10:1758835918793326.
Key Points: - CDK4/6 inhibitor-induced neutropenia (usually with palbociclib and fulvestrant) is typically less severe: - Grade 3/4 neutropenia usually resolves within 7 days. - Missing pancytopenia and lower infection rates compared to chemotherapy. - G-CSF may not be necessary. - Chemotherapy-induced neutropenia is more severe and frequent: - Grade 4 neutropenia in over 30% of patients within the first 4 cycles. - Up to 23% experience febrile neutropenia. - Mortality rate of around 5%. - CDK4/6 inhibitor-induced neutropenia shows a favorable profile: - Lower rates of both grade 4 neutropenia and febrile neutropenia compared to chemotherapy. - Neutropenia often decreases with each treatment cycle, suggesting no cumulative toxicity. - Aligns with the targeted mechanism of CDK4/6 inhibitors.
If the patient does not object, it may be possible to add testing for PIK3CA or AKT1/PTEN-activating mutations for reference in the future selection of drugs.
[exam findings]
[MedRec]
[chemotherapy]
2024-07-18 - cytarabine 30mg/m2 20mg NS 100mL Q12H 30min D1-7 (low dose Ara-C)
2024-06-11 - cytarabine 30mg/m2 20mg NS 100mL Q12H 30min D1-7 (low dose Ara-C)
2024-05-28 - azacitidine 100mg SC D1-3 (Vidaza)
2024-03-29 - cytarabine 30mg/m2 20mg NS 100mL Q12H 30min D1-7 (low dose Ara-C)
2024-03-19 - azacitidine 100mg SC D1-3 (Vidaza)
2024-03-05 - azacitidine 100mg SC D1-3 (Vidaza)
2024-02-20 - azacitidine 100mg SC D1-3 (Vidaza)
2024-02-06 - azacitidine 100mg SC D1-3 (Vidaza)
2024-01-15 - cytarabine 30mg/m2 30mg NS 100mL Q12H 30min D1-7 (low dose Ara-C)
[alternate day dosing of Targocid for renal adjustment]
This patient has been prescribed Targocid (teicoplanin 800mg) QD, and her eGFR was 43.06 ml/min/1.73m² on 2024-07-26.
According to the Sanford Guide, the renal adjustment for this medication should be 6-12 mg/kg every other day. For this patient, with a body weight of 70 kg, it is recommended to adjust the dosage interval to alternate days.
[managing unstable AML with cytarabine and venetoclax]
Lab data:
The patient’s AML control is unstable. The blast percentage reduction with Vidaza (azacitidine) is less effective than with cytarabine, but the effect of cytarabine (maintaining blasts < 20%) lasts only about two weeks. According to our hospital’s chemotherapy protocol (version 2023-02-20), the administration method from the reference “Cancer. 2007 Mar 15;109(6):1114-24” for low dose Ara-C is 20 mg twice daily for 10 days, whereas the patient received it for only 7 days.
Given the patient’s ECOG PS is 2, low dose cytarabine combination therapy might be considered. The oral BCL2 inhibitor venetoclax is covered by NHI, with the reimbursement rule requiring it to be used with low-dose cytarabine for newly diagnosed AML patients who cannot undergo high-intensity chemotherapy:
[pre-existing anemia and thrombocytopenia complicate chemotherapy assessment]
The patient was diagnosed with AML at the beginning of this year. Throughout the HIS5 lab data, her HGB and PLT levels have never reached the lower limit of the normal range, even with 18 blood transfusions. The persistent anemia and thrombocytopenia developed even before the initialization of chemotherapy (2024-01-15).
Both azacitidine and cytarabine are known to be associated with anemia and thrombocytopenia, so the contribution of chemotherapy cannot be ruled out. However, given the patient’s pre-existing anemia and thrombocytopenia, it is difficult to determine the extent to which chemotherapy has contributed.
2024-04-20 HGB 7.8 g/dL
2024-04-17 HGB 7.3 g/dL
2024-04-11 HGB 7.6 g/dL
2024-04-04 HGB 6.8 g/dL
2024-04-01 HGB 6.5 g/dL
2024-03-28 HGB 7.8 g/dL
2024-03-26 HGB 7.5 g/dL
2024-03-21 HGB 7.9 g/dL
2024-03-19 HGB 8.3 g/dL
2024-03-12 HGB 7.8 g/dL
2024-03-05 HGB 7.1 g/dL
2024-02-20 HGB 7.2 g/dL
2024-02-06 HGB 7.5 g/dL
2024-01-31 HGB 8.6 g/dL
2024-01-24 HGB 8.5 g/dL
2024-01-22 HGB 7.9 g/dL
2024-01-18 HGB 8.2 g/dL
2024-01-15 HGB 7.8 g/dL
2024-01-11 HGB 7.9 g/dL
2024-01-08 HGB 6.8 g/dL
2024-01-05 HGB 8.2 g/dL
2024-01-04 HGB 6.7 g/dL
2024-01-03 HGB 6.9 g/dL
2024-06-09 PLT 29 *10^3/uL
2024-06-04 PLT 24 *10^3/uL
2024-05-28 PLT 16 *10^3/uL
2024-05-14 PLT 24 *10^3/uL
2024-04-30 PLT 30 *10^3/uL
2024-04-22 PLT 94 *10^3/uL
2024-04-20 PLT 30 *10^3/uL
2024-04-17 PLT 35 *10^3/uL
2024-04-11 PLT 3 *10^3/uL
2024-04-04 PLT 55 *10^3/uL
2024-04-01 PLT 36 *10^3/uL
2024-03-28 PLT 103 *10^3/uL
2024-03-26 PLT 25 *10^3/uL
2024-03-21 PLT 94 *10^3/uL
2024-03-19 PLT 33 *10^3/uL
2024-03-12 PLT 23 *10^3/uL
2024-03-05 PLT 39 *10^3/uL
2024-02-20 PLT 44 *10^3/uL
2024-02-06 PLT 63 *10^3/uL
2024-01-31 PLT 8 *10^3/uL
2024-01-24 PLT 65 *10^3/uL
2024-01-22 PLT 17 *10^3/uL
2024-01-18 PLT 83 *10^3/uL
2024-01-15 PLT 22 *10^3/uL
2024-01-11 PLT 33 *10^3/uL
2024-01-08 PLT 11 *10^3/uL
2024-01-05 PLT 64 *10^3/uL
2024-01-04 PLT 134 *10^3/uL
2024-01-03 PLT 40 *10^3/uL
A low dose of Ara-C was administered (again) on 2024-03-29, resulting in a reduction of peripheral blast percentage to around 5%. Concurrently, grade 3 anemia has developed, suggesting the need for LPRBC transfusion.
2024-04-04 Blast 5.1 %
2024-04-01 Blast 4.5 %
2024-03-28 Blast 19.2 %
2024-04-04 HGB 6.8 g/dL
2024-04-01 HGB 6.5 g/dL
[persistent blast percentage despite chemotherapy, considering LPRBC transfusion]
The patient underwent a 7-day low-dose Ara-C treatment starting on 2024-01-15, followed by four biweekly 3-day sessions of 100mg azacitidine, concluding on 2024-03-21.
Despite these treatments, the blast percentage in the peripheral blood rose from a nadir of 1.1% on 2024-01-22 to approximately 20%, indicating that remission was not achieved. With hemoglobin levels below 8 g/dL, a leukapheresis red blood cell (LPRBC) transfusion may be necessary if symptoms persist.
2024-03-28 Blast 19.2 %
2024-03-26 Blast 21.6 %
2024-03-21 Blast 22.2 %
2024-03-19 Blast 21.0 %
2024-03-12 Blast 13.5 %
2024-03-05 Blast 12.8 %
2024-01-22 Blast 1.1 %
2024-01-18 Blast 3.2 %
2024-01-15 Blast 7.7 %
2024-01-11 Blast 7.2 %
2024-01-08 Blast 6.1 %
2024-03-28 HGB 7.8 g/dL
2024-03-26 HGB 7.5 g/dL
2024-03-21 HGB 7.9 g/dL
After 5 days of hydroxyurea treatment (500mg BID from 2024-01-04 to 2024-01-08), the blast percentage in peripheral blood significantly reduced from nearly 20% to below 10%.
Hydroxyurea can be used off-label for cytoreduction in AML, effectively normalized the WBC count to 4.1K/uL by 2024-01-08. Consequently, further administration of hydroxyurea is currently unnecessary.
[Proper Storage and Usage of Flumarin (Flomoxef Sodium)]
According to the Flumarin (flomoxef sodium) package insert, the medication should be used as soon as possible after preparation. If it must be prepared in advance, it should be used within 6 hours when stored at room temperature or within 24 hours when refrigerated.
[exam findings]
[MedRec]
[chemotherapy]
[delaying folfox treatment due to low ANC levels]
Recent lab results from 2024-07-24 show a WBC count of 1.35K, a neutrophil percentage of 46.2%, thus an estimated ANC of 624/uL. The planned FOLFOX treatment is recommended to be delayed until the ANC rises above 1500/uL. In urgent cases, the ANC should be above 1000/uL before administration.
[exam findings]
[lab data]
2024-07-17 Anti HTLV I/II Nonreactive
2024-07-17 Anti HTLV I/II Value 0.05 S/CO
2024-07-17 Anti-HBc Reactive
2024-07-17 Anti-HBc Value 5.13 S/CO
2024-07-17 Anti-HBs 38.56 mIU/mL
2024-07-17 HBsAg Nonreactive
2024-07-17 HBsAg Value 0.28 S/CO
2024-07-17 Anti-HCV Nonreactive
2024-07-17 Anti-HCV Value 0.07 S/CO
[exam findings]
[MedRec]
(not posted yet)
Testing for human T-cell lymphotropic virus (HTLV) can sometimes be helpful for people who appear to have peripheral T-cell lymphoma. In rare cases, HTLV can cause adult T-cell leukemia/lymphoma. This type of T-cell lymphoma can look very similar to peripheral T-cell lymphoma, but is treated differently. The anti HTLV I/II showed nonreactive and the value was 0.05 S/CO on 2024-07-17.
People with human immunodeficiency virus (HIV) tend to have a weakened immune system. So if the patient has peripheral T-cell lymphoma, it might be beneficial to know whether she also has HIV
[diagnosis]
[exam findings]
[MedRec]
[consultation]
[surgical operation]
2020-12-11 Colon cancer with single liver metastasis s/p RFA (2 sessions) using RVS
2020-01-19
2019-10-22
[radiotherapy]
[chemotherapy]
[monitoring tumor markers and assessing disease progression]
LPRBC transfusion is planned for HGB at 8.9 g/dL. Tumor markers CEA and CA199 are still on an upward trend, with CA199 tripling in less than one month. The last abdominal CT was conducted 3 months ago on 2024-04-24. It is recommended to update medical imaging to check for disease progression and determine if the treatment regimen needs adjustment.
2024-07-16 CEA (NM) 70.622 ng/ml
2024-06-28 CEA (NM) 75.866 ng/ml
2024-05-07 CEA (NM) 56.994 ng/ml
2024-04-12 CEA (NM) 57.916 ng/ml
2024-03-26 CEA (NM) 47.810 ng/ml
2024-02-16 CEA (NM) 37.327 ng/ml
2024-01-03 CEA (NM) 33.875 ng/ml
2024-07-16 CA-199 (NM) 672.340 U/ml
2024-06-28 CA-199 (NM) 194.991 U/ml
2024-05-07 CA-199 (NM) 164.319 U/ml
2024-04-12 CA-199 (NM) 167.790 U/ml
2024-03-26 CA-199 (NM) 173.605 U/ml
2024-02-16 CA-199 (NM) 133.240 U/ml
2024-01-03 CA-199 (NM) 107.208 U/ml
[flomoxef for Escherichia coli infection]
A chest X-ray on 2024-06-03 showed patchy consolidation in the RLL of the lung, might be suggestive of bronchopneumonia. There was also blunting of the right costophrenic angle, likely due to pleural effusion. Despite normal CRP and PCT readings, the patient’s cough sputum culture revealed Escherichia coli 4+, which is sensitive to Flumarin (flomoxef sodium, MIC ≤ 2). Flumarin was initiated on 2024-06-07. No fever over 37°C has been observed since then.
[monitoring progression: bone scans, CT, and tumor markers]
Bone scans and CT imaging are scheduled to monitor the progression, as tumor markers CEA and CA199 have shown an increasing trend over the past 6 months.
Laboratory results from 2024-04-22 indicate there are no contraindications to proceeding with a new session of FOLFOX chemotherapy for the treatment of the patient’s condition.
2024-04-12 CEA (NM) 57.916 ng/ml
2024-03-26 CEA (NM) 47.810 ng/ml
2024-02-16 CEA (NM) 37.327 ng/ml
2024-01-03 CEA (NM) 33.875 ng/ml
2023-11-21 CEA (NM) 33.072 ng/ml
2024-04-12 CA-199 (NM) 167.790 U/ml
2024-03-26 CA-199 (NM) 173.605 U/ml
2024-02-16 CA-199 (NM) 133.240 U/ml
2024-01-03 CA-199 (NM) 107.208 U/ml
2023-11-21 CA-199 (NM) 106.235 U/ml
[assessing bloody stools: tranexamic acid use in ongoing GI bleeding management]
The patient reported experiencing bloody stools for a week and underwent an EGD and sigmoidoscopy on 2024-02-12 (HGB 9.9 g/dL).
The presence of bloody stools suggests the possibility of GI bleeding. However, the EGD did not provide a definitive diagnosis due to the presence of food debris. While atrophic gastritis could be associated with the bleeding, further examination is required for a conclusive determination. The suspected rectal cancer, identified separately, demands prompt and focused attention due to its severity.
HR has been stable at 70 to 80, with no signs of resting tachycardia observed.
Hemoclot (tranexamic acid) was administered starting the night of 2024-02-12. Should the bleeding continue, it is often possible to manage the condition with therapeutic interventions during colonoscopy or angiography.
Lab results from 2024-01-30 did not reveal any significant findings that would contraindicate proceeding with a new session of the FOLFOX regimen.
The active medication list has been updated to include repeat prescriptions from our gastroenterologist (2023-12-30), cardiologist (2023-12-28), neurologist, urologist (2023-12-15), and psychosomatic physician (2023-11-15), with no discrepancies noted.
Lab results obtained on 2023-12-21 were largely unremarkable with the exception of mild anemia (HGB 9.5 g/dL). Due to this finding, the new session FOLFOX regimen has been continued on 2023-12-21.
Medications from repeat prescriptions issued by our neurologist, urologist (2023-12-15), and psychosomatic physician (2023-11-15) have been successfully integrated into the active medication list. No discrepancies were identified.
After checking the PharmaCloud database and the patient’s current medication list, it is confirmed that all medications from the refill order have been taken. No discrepancies are found.
[reconciliation]
The patient has attended multiple departments in our hospital and has been issued several repeat prescriptions that remain valid to date:
2023-09-19 Gastroenterology: Ulstop (famotidine), Gaslan (dimethylpolysiloxane), Mopride (mosapride citrate)
2023-09-15 Cardiology: Januvia (sitagliptin), Eliquis (apixaban), Zandip (lercanidipine)
2023-09-08 Urology: Urief (silodosin), Betmiga (mirabegron)
2023-09-01 Neurology: Muaction (tramadol), Kentamin (Vit B1, B6, B12), Trynol (amitriptyline), Neurontin (gabapentin), CaCO3, U-Ca (calcitriol)
2023-08-30 Psychosomatic Medicine: Alpraline (alprazolam)
All these medications are actively being used by the patient, and no inconsistencies have been identified.
[tumor markers]
The most recent CT scan of the abdomen dated 2023-06-30 shows no evidence of tumor recurrence in the rectum following LAR surgery. While a lesion in S5 of the liver post-RFA indicates complete recovery, a previously detected lesion in S8 and some liver cysts in the left lobe remain stable, suggesting the need for continued surveillance. However, given the increasing trend of the tumor markers CEA and CA199 in recent months, further imaging or testing may be required to obtain an updated status of the disease.
2023-09-28 CEA (NM) 41.773 ng/ml
2023-08-29 CEA (NM) 41.022 ng/ml
2023-08-01 CEA (NM) 28.657 ng/ml
2023-06-27 CEA (NM) 32.370 ng/ml
2023-06-06 CEA (NM) 38.089 ng/ml
2023-05-09 CEA (NM) 29.020 ng/ml
2023-04-11 CEA (NM) 29.090 ng/ml
2023-03-07 CEA (NM) 30.892 ng/ml
2023-02-22 CEA (NM) 22.304 ng/ml
2023-01-20 CEA (NM) 29.331 ng/ml
2023-09-28 CA-199 (NM) 128.119 U/ml
2023-08-29 CA-199 (NM) 124.920 U/ml
2023-08-01 CA-199 (NM) 100.17 U/ml
2023-06-27 CA-199 (NM) 102.499 U/ml
2023-06-06 CA-199 (NM) 108.696 U/ml
2023-05-09 CA-199 (NM) 99.780 U/ml
2023-04-11 CA-199 (NM) 94.910 U/ml
2023-03-07 CA-199 (NM) 91.315 U/ml
2023-02-22 CA-199 (NM) 66.824 U/ml
2023-01-20 CA-199 (NM) 70.223 U/ml
On 2023-06-23, our cardiologist prescribed Januvia (sitagliptin), Eliquis (apixaban), and Zandip (lercanidipine) for the patient, while on 2023-07-01, our gastroenterologist prescribed Ulstop (famotidine), Gaslan (dimethylpolysiloxane), and Mopride (mosapride citrate). All medications, with the exception of Mopride, are currently on the active medication list. Please determine if the use of Mopride is still necessary.
This patient just refilled his prescription for Januvia (sitagliptin), Eliquis (apixaban), Zanidip (lercanidipine), Betmiga (mirabegron), Urief (silodosin) on 2023-07-11 at a local pharmacy and these drugs are now added to the active medication list with no reconciliation issues found.
According to the PharmaCloud database, the patient has solely been using our hospital for both outpatient and inpatient services over the past three months.
The patient visited our Neurology and Psychosomatic Medicine OPD on 2023-06-09 for chemotherapy-related polyneuropathy, L spine radiculopathy, suspected mild cognitive impairment, and insomnia. Refillable prescriptions were given for Muaction (tramadol), Kentamin (B1, B6, B12), Trynol (amitriptyline), Neurontin (gabapentin), calcium carbonate, U-Ca (calcitriol), and Alpraline (alprazolam). These drugs are appropriately reflected on the current active medication list. No issues were identified in the medication reconciliation process.
A review of PharmaCloud records did not identify any medication reconciliation issues.
This patient’s chemotherapy-induced polyneuropathy may be more likely due to the oxaliplatin component of the FOLFOX regimen, which was started in Oct 2021. Appropriate measures have been taken, including the addition of Kentamin (B1, B6, B12) and Neurontin (gabapentin) to the patient’s active medication regimen as prescribed by our neurologist.
The patient’s CEA and CA199 levels have shown similar upward trends in recent months, which may indicate that the disease is becoming more resistant to current treatment. This may require further evaluation and possible adjustments to the future treatment plan.
2023-05-09 CEA (NM) 29.020 ng/ml
2023-04-11 CEA (NM) 29.090 ng/ml
2023-03-07 CEA (NM) 30.892 ng/ml
2023-02-22 CEA (NM) 22.304 ng/ml
2023-05-09 CA-199 (NM) 99.780 U/ml
2023-04-11 CA-199 (NM) 94.910 U/ml
2023-03-07 CA-199 (NM) 91.315 U/ml
2023-02-22 CA-199 (NM) 66.824 U/ml
CEA and CA199 levels have been consistently above the normal range since Oct 2022.
The patient is being treated for bilateral L5 and bilateral below wrist numbness caused by chemotherapy-related polyneuropathy and L spine radiculopathy. The treatment plan, including the use of Kentamine (B1 50mg + B6 50mg + B12 500ug), Neurontin (gabapentin), Trynol (amitriptyline), and Muaction (tramadol), has been properly prescribed by our neurologist on 2023-03-24.
As of now, the patient has had one bowel movement on 2023-03-26 and there are no signs of constipation. Loperamide 2mg PRNQ4H has been prepared in advance if needed.
Based on the TPR panel, the patient’s underlying conditions of hypertension and diabetes are well controlled.
There were no medication reconciliation issues identified and there are no issues with the current active prescription.
As of now, the patient’s TPR, blood pressure, and blood sugar level remain stable. The lab data 2023-02-19 showed grossly normal readings, except for slightly high BUN and slightly low levels of albumin and calcium.
The recently prescribed drugs that were disclosed in the NHI PharmaCloud System have been appropriately prescribed during this hospital stay. No medication reconciliation issues have been found in the patient.
2020 ASCO guidelines suggest that clinicians may offer duloxetine to patients with chemotherapy-induced peripheral neuropathy, and 2020 joint ESMO/EONS/EANO guidelines recommend duloxetine for treatment of neuropathic pain in this setting. ref: Loprinzi CL, Lacchetti C, Bleeker J, et al. Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: ASCO Guideline Update. J Clin Oncol 2020; 38:3325.
Duloxetine for adult patients with chemotherapy-induced peripheral neuropathy: Oral initial 30 mg once daily for 1 week, then 60 mg once daily. Ref: Smith EM, Pang H, Cirrincione C, et al; Alliance for Clinical Trials in Oncology. Effect of duloxetine on pain, function, and quality of life among patients with chemotherapy-induced painful peripheral neuropathy: a randomized clinical trial. JAMA. 2013;309(13):1359-67. doi:10.1001/jama.2013.2813
There is Cymbalta (duloxetine 30mg/cap) available in the stock.
In this case, the patient had chemotherapy related polyneuropathy and L spine radiculopathy, which was evaluated by our neurologist on 2022-11-14. Neurontin (gabapentin 100mg/cap) 1# BID has been prescribed.
At this time, vital signs appear to be stable. According to the lab data on 2022-12-01, there was a slight pancytopenia, but overall the results were normal.
There is no issue with the active prescription.
Duloxetine is recommended for the mitigation of chemotherapy-related sensorimotor polyneuropathy (Type of recommendation: evidence based, benefits equal harms; Evidence quality: intermediate; Strength of recommendation: moderate. Ref: Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: ASCO Guideline Update. Journal of Clinical Oncology 2020 38:28, 3325-3348)
Duloxetine for chemotherapy-induced peripheral neuropathy (off-label use): Oral initial: 30 mg once daily for 1 week, then 60 mg once daily.
Colonoscopy (2022-05-20) showed local recurrent cancer at low rectum.
CEA levels continue to rise in recent months:
CA199 exhibits a similar trend to CEA
Lab data on 2022-07-18 showed generally normal readings except for slight anemia.
Lab data on 2022-05-16 showed that liver and kidney function, electrolytes and CBC were generally normal.
Biomarkers
The last CT scan was performed on 2022-01-04, so the image may need to be updated.
According to in-hospital database, the patient had mild drug allergy with: Sketa, Warfarin, Dipyridamole, Valaciclovir, Solaxin (chlorzoxazone).
[lab data]
[exam findings]
[chemotherapy]
[initiate ETV or TAF before or with cancer therapy]
Lab data:
Interpretation:
However, this limited data cannot definitively differentiate between:
Next Steps:
Entecavir or tenofovir is recommended to be initiated as soon as possible relative to the start of anticancer therapy in this patient.
[MedRec]
[chemotherapy]
[trends in blood potassium and supplementation]
Tracking the patient’s blood potassium changes over the past three months reveals a significant downward trend. Since 2024-06, there have been more instances of levels falling below 3 mmol/L, with a drop to less than 2 mmol/L on 2024-07-18. Potassium supplementation is currently being administered as an appropriate treatment.
[managing elevated CRP, rising PCT, and ALT levels]
Lab results show that CRP has been persistently elevated, making it less sensitive for detecting infections. In contrast, PCT and ALT levels have rapidly increased, indicating a potential new infection and liver damage. Flumarin (flomoxef) is currently being administered, and the addition of BaoGan (silymarin) might be considered.
2024-07-18 ALT 110 U/L
2024-06-27 ALT 18 U/L
2024-06-07 ALT 17 U/L
2024-07-18 Procalcitonin (PCT) 1.78 ng/mL
2024-06-24 Procalcitonin (PCT) 0.15 ng/mL
2024-06-20 Procalcitonin (PCT) 0.11 ng/mL
2024-06-11 Procalcitonin (PCT) 0.20 ng/mL
2024-07-18 CRP 22.2 mg/dL
2024-07-12 CRP 27.3 mg/dL
2024-07-06 CRP 18.2 mg/dL
2024-07-02 CRP 21.3 mg/dL
2024-06-28 CRP 26.3 mg/dL
2024-06-27 CRP 23.7 mg/dL
2024-06-23 CRP 20.4 mg/dL
2024-06-20 CRP 14.1 mg/dL
2024-06-11 CRP 13.8 mg/dL
2024-06-07 CRP 26.1 mg/dL
[lab data]
2023-07-24 Anti-HCV Nonreactive
2023-07-24 Anti-HCV Value 0.25 S/CO
2023-07-24 Anti-HBc Reactive
2023-07-24 Anti-HBc-Value 6.92 S/CO
2023-07-24 Anti-HBs 7.37 mIU/mL
2023-07-24 HBsAg Nonreactive
2023-07-24 HBsAg (Value) 0.27 S/CO
[exam findings]
[MedRec]
[consultation]
This is a 50 y/o male patient with underlying alcoholism, gout, GERD. He was admitted this time under the impression of: UGI bleeding, cellulitis of foot, and colitis of ascending colon and cecum, the patient was admitted for further evaluation and management. We were consulted for the irritable mood and suspect visual hallucination at night.
According to the patient and his wife: A 50-year-old male, living with his wife and son, was a logistics driver for over 10 years and has no history of psychiatric treatment. He left his job a month ago, stating that he resigned due to disagreements with his supervisor. He began social drinking in high school, and over time, the amount and strength of alcohol consumed gradually increased. He now drinks 350ml bottles of sorghum liquor, 1-2 bottles daily. When not drinking, he experiences cravings and withdrawal symptoms, and when drunk, he talks nonsense and reports seeing strange things.
The patient and his family indicate that about three weeks ago, after leaving his job, he resolved to stop drinking. He claims that he has not touched alcohol since that day (though his account is somewhat inconsistent). He has been staying at home feeling gloomy, depressed, and irritable, but denies having suicidal thoughts. His wife notes that he was mentally clear during this period but started feeling general weakness before admission to the hospital. After admission, he exhibited irritability, restlessness, incoherent speech, and possible visual hallucinations.
Upon visit, he showed mild muddy spirit, limited orientation to time, people and place, rather stable mood. Coherant but sometimes irrelevant speech. Currently denied suicide ideation, denied hallucination. Poor memory function for years. Confabulation(+/-), nystagmus(+), unsteady gait, withdrawal symptom(+): tremor, palpitation.
[chemotherapy]
2024-06-26 - fluorouracil 800mg/m2 1200mg NS 500mL 24hr D1-5 + hydroxyurea 1000mg PO Q12H D1-5
2024-02-22 - carboplatin AUC 2 170mg D5W 250mL 1hr + MgSO4 10% 20mL NS 100mL (CCRT)
2024-02-08 - carboplatin AUC 2 170mg D5W 250mL 1hr (CCRT)
2024-02-01 - carboplatin AUC 2 170mg D5W 250mL 1hr (CCRT)
2024-01-25 - carboplatin AUC 2 170mg D5W 250mL 1hr (CCRT)
2024-01-18 - carboplatin AUC 2 170mg D5W 250mL 1hr (CCRT)
2024-01-10 - carboplatin AUC 2 170mg D5W 250mL 1hr (CCRT)
2023-12-22 - docetaxel 40mg/m2 60mg NS 150mL 1hr + carboplatin AUC 3 100mg NS 100mL 2hr + fluorouracil 750mg/m2 1000mg D5W 500mL 24hr D1-2 (TPF Q3W. Carbo AUC 1.5)
2023-11-18 - docetaxel 40mg/m2 60mg NS 150mL 1hr + carboplatin AUC 3 100mg NS 100mL 2hr + fluorouracil 750mg/m2 1000mg D5W 500mL 24hr D1-2 (TPF Q3W. Carbo AUC 1.5)
2023-11-16 - docetaxel 40mg/m2 60mg NS 150mL 1hr + carboplatin AUC 3 100mg NS 100mL 2hr + fluorouracil 750mg/m2 1000mg D5W 500mL 24hr D1-2 (TPF Q3W. Carbo AUC 1.5)
2023-11-11 - docetaxel 40mg/m2 60mg NS 150mL 1hr + carboplatin AUC 3 100mg NS 100mL 2hr + fluorouracil 750mg/m2 1000mg D5W 500mL 24hr D1-2 (TPF Q3W. Carbo AUC 1.5)
2023-10-14 - docetaxel 30mg/m2 45mg NS 150mL 1hr + carboplatin AUC 3 100mg NS 100mL 2hr + fluorouracil 750mg/m2 1000mg D5W 500mL 24hr D1-2 (TPF Q3W. Carbo AUC 1.5)
2023-09-22 - ………………………………. carboplatin AUC 3 100mg NS 100mL 2hr + fluorouracil 750mg/m2 1000mg D5W 500mL 24hr D1-2 (TPF Q3W. no taxel; Carbo AUC 1.5)
2023-09-15 - ………………………………. carboplatin AUC 3 100mg NS 100mL 2hr + fluorouracil 750mg/m2 1000mg D5W 500mL 24hr (TPF Q3W. no taxel; CrCl 47 Carbo AUC 1.5; 5FU C1 24hr)
2023-08-22 - docetaxel 40mg/m2 0mg NS 250mL 1hr + cisplatin 40mg/m2 0mg NS 500mL + fluorouracil 2000mg/m2 0mg NS 500mL 46hr (TPF Q3W) [TEMP] (not conducted)
[hyperkalemia episodes]
Episodes of hyperkalemia have occurred several times in the past 5 months. During this period, the highest recorded serum creatinine level was 1.8mg/dL, and the eGFR consistently remained above 40 mL/min/1.73m^2, suggesting that the kidneys should still have the capacity to excrete excess potassium.
Upon reviewing the patient’s recent medication history, it was found that olmesartan, a component of Sevikar, could be a potential cause of hyperkalemia, especially considering the patient’s risk factors such as renal dysfunction, diabetes mellitus, concurrent use of potassium-sparing diuretics, potassium supplements, and/or potassium-containing salts. Sevikar has already been discontinued. Additionally, propranolol, which is currently being used, has been sporadically reported in post-marketing studies to be associated with hyperkalemia, although it is considered a less likely cause.
Could hypoaldosteronism be a potential cause in this case?
[reconciliation]
On 2023-10-18, this patient just refilled his repeat prescription for a 28-day supply of MgO, lansoprazole, sennoside, Kentamin, sodium ferrous citrate, propranolol, febuxostat, quetiapine fumarate, lorazepam. No discrepancies have been found with these medications currently in use.
[alcohol abstinence]
Abstaining from alcohol is the foundation of managing alcohol-associated cirrhosis. This abstinence has been linked to improvements in fibrosis, as well as lower hepatic venous pressure gradients.
Lab tests (2023-11-07) revealed normal AST, ALT, and total bilirubin levels. If the cirrhosis worsens and becomes decompensated, Baraclude (entecavir 1mg) may be a viable treatment option.
[reconciliation]
Recent MCV and MCH levels have consistently been on the upper end of their normal range, suggesting that iron deficiency anemia is less probable. The ongoing use of the iron supplement Foliromin (ferrous sodium citrate) may be reduced.
2023-08-21 MCV 92.3 fL
2023-07-24 MCV 93.0 fL
2023-07-14 MCV 92.6 fL
2023-06-10 MCV 92.3 fL
2023-08-21 MCH 31.0 pg
2023-07-24 MCH 30.6 pg
2023-07-14 MCH 30.2 pg
2023-06-10 MCH 30.6 pg
[exam findings]
[MedRec]
[surgical operation]
[immunochemotherapy]
2024-07-17 - amivantamab 350mg NS 240mL 12hr
2024-07-16 - nivolumab 100mg NS 100mL 1hr
2024-07-15 - ramucirumab 500mg NS 250mL 1.5hr
2024-06-20 - amivantamab 350mg NS 240mL 12hr
2024-06-19 - nivolumab 100mg NS 100mL 1hr
2024-06-18 - ramucirumab 500mg NS 250mL 1.5hr
2024-05-28 - amivantamab 350mg NS 240mL 12hr
2024-05-24 - nivolumab 100mg NS 100mL 1hr
2024-05-23 - ramucirumab 500mg NS 250mL 1.5hr
2024-04-10 - nivolumab 100mg NS 100mL 1hr
2024-04-09 - ramucirumab 500mg NS 250mL 1.5hr
2024-03-11 - ipilimumab 50mg NS 50mL 30min
2024-03-09 - nivolumab 100mg NS 100mL 1hr
2024-03-08 - ramucirumab 500mg NS 250mL 1.5hr
2024-01-19 - ipilimumab 50mg NS 50mL 30min
2024-01-18 - nivolumab 100mg NS 100mL 1hr
2024-01-17 - ramucirumab 500mg NS 250mL 1.5hr
2023-12-19 - nivolumab 100mg NS 100mL 1hr
2023-12-18 - ramucirumab 500mg NS 250mL 1.5hr
2023-11-17 - nivolumab 100mg NS 100mL 1hr
2023-11-16 - ramucirumab 500mg NS 250mL 1.5hr
2023-10-16 - ramucirumab 300mg NS 250mL 1.5hr
2023-08-21 - ramucirumab 300mg NS 250mL 1.5hr
2023-07-26 - ramucirumab 300mg NS 250mL 1.5hr
[dermatologic side effects in in the patient on “amivantamab”, nivolumab, and ramucirumab]
The patient has developed a skin rash while on the regimen including amivantamab, nivolumab, and ramucirumab. Each of these drugs has documented dermatologic side effects:
Given the overlapping potential for dermatologic side effects from all three medications, it is challenging to pinpoint the exact cause of the rash. Our dermatologist recommended Sinpharderm (urea) and tetracycline for external use on 2024-07-10 as potential therapies that may effectively alleviate patient discomfort.
Amivantamab Dermatologic Toxicity Management
The patient is currently using 350 mg, the lowest recommended dose (second dose reduction). There are no lower documented doses. Considering potential risk factors related to dosage, it might be an option temporarily discontinuing the drug and observing if skin symptoms improve. If improvement occurs, reassess the possibility of re-challenge.
[exam findings]
[consultation]
[immunochemotherapy]
[Elevated Labs Suggest Sepsis - Antibiotics Started]
Recent lab data and interpretation:
Given the combination of the following evidences, there is a high probability that this patient is experiencing sepsis. This condition requires urgent medical attention to identify the source of infection, provide appropriate antimicrobial therapy, and manage any organ dysfunction.
Blood cultures were ordered and the broad-spectrum antibiotic Cefim (cefepime) 2g Q8H IVD is currently being used. No medication discrepancies were noted.
[exam findings]
[MedRec]
[immunochemotherapy]
[switching medication due to deteriorating kidney function]
The patient’s renal function is deteriorating, with the latest eGFR dropping below 15 as of 2024-07-13.
The package insert for Vemlidy (tenofovir alafenamide) advises against its use in patients with CrCl < 15. However, Baraclude (entecavir 0.5mg) may be considered as an alternative, administered every three days (Q3D) in patients with CrCl between 10 and <30 mL/minute.
[exam finding]
[MedRec]
[surgical operation]
2022-05-27 Excision of chest wall and repair of diaphragmatic defect.
2020-03-23 Enterolysis with bowel decompression
2019-12-31 Partial nephrectomy
2019-10-30 Closure of enterostomy or Colostomy (loop or double-barrel)
2019-03-27 Left hemicolectomy or sigmoid colectomy with anastomosis with lymph node
2019-03-23 Enterostomy for suspected S-colon cancer with obstruction
drug allergy
[immunochemotherapy]
[strategies for handling liver deterioration]
The patient’s liver function is deteriorating, as indicated by recent rapid increases in ALT, AST, bilirubin, and decreased albumin levels.
It is recommended to add BaoGan (silymarin) and delay the next session of “Erbitux + FOLFIRI” until there is evidence of recovery. In addition, it is recommended to monitor HBV DNA levels (check for HBV reactivation) to determine whether the dose of Baraclude (entecavir) should be adjusted from 0.5mg to 1mg or switched to Vemlidy (tenofovir alafenamide, if resistance develops).
2024-07-15 ALT 106 U/L
2024-07-12 ALT 34 U/L
2024-07-15 AST 160 U/L
2024-07-12 AST 48 U/L
2024-07-08 AST 40 U/L
2024-06-24 AST 21 U/L
2024-07-15 Bilirubin total 1.79 mg/dL
2024-07-12 Bilirubin total 1.35 mg/dL
2024-07-08 Bilirubin total 1.12 mg/dL
2024-06-24 Bilirubin total 0.62 mg/dL
2024-07-15 Bilirubin direct 1.12 mg/dL
2024-07-12 Bilirubin direct 0.64 mg/dL
2024-05-13 Bilirubin direct 0.19 mg/dL
2024-07-15 Albumin (BCG) 2.7 g/dL
2024-07-12 Albumin (BCG) 3.2 g/dL
2024-07-08 Albumin (BCG) 3.0 g/dL
2024-07-12 CEA 8.08 ng/mL
2024-05-28 CEA 5.35 ng/mL
2024-05-21 CEA 5.19 ng/mL
2024-05-09 CEA 4.64 ng/mL
2024-04-25 CEA 3.10 ng/mL
2024-03-27 CEA 2.73 ng/mL
The patient’s vital signs, laboratory data (2022-10-11), and the disease are in a generally stable state.
There is no issue with the active prescription. It is recommended that the last abdomen CT image be updated as it is dated 2022-04-13. A metastatic adenocarcinoma around the left 11th and 12th ribs (2022-05-03 pathology) might be surgically removed if it is symptomatic and feasible.
There was a generally normal lab result on 2022-09-12 and a relatively stable TPR and BP reading during this hospital stay. With the current regimen, the patient has tolerated it. In this case, the patient has only a muscle power of 4 or less, so some assistive devices might be beneficial.
[MedRec]
[administering OxyNorm via feeding tubes]
When administering OxyNorm (oxycodone) Immediate Release capsules via nasogastric feeding or gastrostomy, start by flushing the tube with water. Open the capsule and directly pour the contents into the tube. Follow this with a flush of 15 mL of water, then rinse the tube at least two more times with 10 mL of water each. Milk or liquid nutritional supplements may be used in place of water.
[lab data]
[exam findings]
[MedRec]
[immunochemotherapy]
[enhancing protein intake in hypoalbuminemia]
Hypoalbuminemia is worsening, and it may be beneficial to administer human albumin to quickly raise the level. Additionally, consulting a nutrition intervention to enhance the patient’s protein intake could also be helpful.
According to the PharmaCloud database, the patient’s medical care has exclusively been provided by our hospital in the recent 3 months. Consequently, no discrepancies in medication reconciliation have been detected.
Based on the PharmaCloud database, the patient has only received medical services from our hospital for the past three months. As a result, no medication reconciliation issues have been identified.
[MedRec]
[immunochemotherapy]
[exam findings]
[MedRec]
[chemotherapy]
[Worsening Normocytic Anemia: Potential Impact on Docetaxel Regimen
]
There has been a concerning trend of worsening normocytic anemia over the past three months. Two recent hemoglobin (HGB) readings have fallen below 8 g/dL.
While the mean corpuscular volume (MCV) remains within the normal range, a noticeable decrease toward microcytosis is evident.
Iron supplementation may be beneficial. However, it’s important to consider that docetaxel itself is associated with a high incidence of anemia (ranging from 65% to 97%, with 8% to 9% developing severe grades 3/4). If the anemia continues to worsen and blood transfusions become intolerable, adjustments to the treatment regimen might be necessary.
[antihyperglycemic meds not used: review T2DM diagnosis (limited data)]
The patient was found to have hyperuricemia and hypomagnesiemia. Magnesium sulfate and Feburic (febuxostat) are being administered to manage these conditions.
There is a single data point for serum glucose on 2023-08-18, with no additional test results present in the HIS5 lab records. Type 2 DM continues to be listed as a diagnosis in recent visit records since 2023-02-09, including the admission note from this hospitalization, yet no antiglycemic medications are currently being administered. It is advisable to review whether this diagnosis should be maintained.
[episodic hyperuricemia: inconsistent Feburic use impedes control]
The patient exhibited episodic hyperuricemia throughout the past year, suggesting inadequate control of his uric acid levels.
In response to these hyperuricemic episodes, Feburic (febuxostat) therapy was administered during several hospitalizations. However, outpatient visits did not consistently prescribe this medication, potentially contributing to the elevated serum uric acid levels.
Therefore, it is recommended to consider either extending Feburic therapy or exploring alternative options such as benzbromarone (on prescription at the OPD visits) for improved management of serum urate levels.
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
[monitoring chest symptoms during TP regimen]
During the first administration of paclitaxel in the last hospital stay, the patient complained of chest tightness and palpitations. On 2024-06-25, the patient reported similar symptoms to our cardiologist, but the 24-hour Holter ECG showed no significant abnormalities.
Please monitor the patient closely for any adverse reactions during this second session of the TP regimen.
[exam findings]
[MedRec]
[surgical operation]
[exam findings]
[MedRec]
2024-03-11 ~ 2024-04-03 POMR General and Gastroenterological Surgery Wu ChaoQun
2022-04-11 ~ 2022-04-15 POMR Hemato-Oncology Gao WeiYao
2022-03-19 ~ 2022-03-23 POMR Gastroenterology Su WeiZhi
[MedRec]
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
2024-04-19 - (FOLFIRI)
2024-04-02 - (FOLFIRI)
2024-03-04 - [leucovorin 20mg/m2 35mg NS 100mL 10min + fluorouracil 400mg/m2 709mg NS 100mL 10min] D1-2 (5-FU CCRT)
2024-02-29 - [leucovorin 20mg/m2 35mg NS 100mL 10min + fluorouracil 400mg/m2 709mg NS 100mL 10min] D1-2 (5-FU CCRT)
2024-01-31 - [leucovorin 20mg/m2 35mg NS 100mL 10min + fluorouracil 400mg/m2 709mg NS 100mL 10min] D1-4 (5-FU CCRT)
2024-01-05 - oxaliplatin 75mg/m2 130mg D5W 250mL 2hr +leucovorin 300mg/m2 530mg NS 250mL 2hr + fluorouracil 300mg/m2 530mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX Q2W)
2023-12-19 - oxaliplatin 75mg/m2 130mg D5W 250mL 2hr +leucovorin 300mg/m2 530mg NS 250mL 2hr + fluorouracil 300mg/m2 530mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX Q2W)
2023-12-05 - oxaliplatin 75mg/m2 130mg D5W 250mL 2hr +leucovorin 300mg/m2 530mg NS 250mL 2hr + fluorouracil 300mg/m2 530mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX Q2W)
2023-11-17 - oxaliplatin 75mg/m2 130mg D5W 250mL 2hr +leucovorin 300mg/m2 530mg NS 250mL 2hr + fluorouracil 300mg/m2 530mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX Q2W)
2023-10-30 - oxaliplatin 75mg/m2 130mg D5W 250mL 2hr +leucovorin 300mg/m2 530mg NS 250mL 2hr + fluorouracil 300mg/m2 530mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX Q2W)
2023-10-06 - oxaliplatin 75mg/m2 130mg D5W 250mL 2hr +leucovorin 300mg/m2 530mg NS 250mL 2hr + fluorouracil 300mg/m2 530mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX Q2W)
2023-07-24 - etoposide 80mg/m2 140mg NS 500mL 2hr D1-3 + carboplatin AUC 4 370mg NS 250mL 2hr D1 (Fytosid 100mg/m2 -> 80mg/m2. eGFR 67 carbo AUC 4)
2023-06-30 - etoposide 80mg/m2 140mg NS 500mL 2hr D1-3 + carboplatin AUC 4 370mg NS 250mL 2hr D1 (Fytosid 100mg/m2 -> 80mg/m2. eGFR 69 WBC 2980 carbo AUC 4)
2023-06-13 - etoposide 100mg/m2 175mg NS 500mL 2hr D1-3 + carboplatin AUC 5 400mg NS 250mL 2hr D1
2023-05-22 - etoposide 100mg/m2 175mg NS 500mL 2hr D1-3 + carboplatin AUC 5 400mg NS 250mL 2hr D1 (Cre 1.08, CrCl 59, carbo AUC 5)
2023-04-28 - etoposide 100mg/m2 175mg NS 500mL 2hr D1-3 + carboplatin AUC 5 400mg NS 250mL 2hr D1 (Cre 1.31, cis -> carbo AUC 5)
2023-04-03 - etoposide 100mg/m2 175mg NS 500mL 2hr D1-3 + NS 500mL 3hr (before cisplatin) + cisplatin 75mg/m2 130mg NS 500mL 24hr D1 + NS 1000mL 3hr (post cisplatin)
[Veklury (remdesivir) dosage consideration for patient with low eGFR]
Veklury (remdesivir) is not recommended for patients with an eGFR less than 30 mL/min. The patient’s eGFR is 46.82 mL/min (2024-07-10), so this is not a contraindication.
The dosing regimen is IV 200 mg as a single dose on day 1, followed by 100 mg once daily.
The package insert and literature do not provide an alternative approach for missing the loading dose. Since the patient received a single dose yesterday evening (ST) and only about half a day has passed before the next daily dose (QD), administering 200 mg this morning may result in a higher-than-expected blood concentration then the trial design. Therefore, it is not recommended to make up for the missed loading dose today.
[HGB drop and bilirubin rise: hemolysis possibility]
Current iron supplementation (Foliromin 50mg ferrous sodium citrate 1# BID PO) is in place (although the MCV of 94 does not indicate microcytosis). An elevation of bilirubin following a decrease in hemoglobin level could suggest hemolysis, which might warrant further investigation.
2024-07-10 Bilirubin total 1.75 mg/dL
2024-07-10 Bilirubin direct 0.47 mg/dL
2024-07-10 HGB 10.4 g/dL
2024-07-08 HGB 8.6 g/dL
2024-07-06 HGB 9.3 g/dL
2024-06-25 HGB 10.2 g/dL
[CCRT for enlarged paraaortic LAP: everolimus as potential next-line treatment, monitoring PLT]
This patient is currently receiving CCRT for his enlarged paraaortic lymph nodes (LAP). The disease eventually developed resistance to the etoposide + carboplatin regimen and the FOLFOX regimen. Newer treatment options, such as everolimus, might need to be considered after the completion of CCRT.
Recent lab data showed values of PLT less than 100K/uL. While this does not yet constitute a critical level, it warrants close monitoring. Other lab findings were unremarkable. No medication discrepancies were identified.
[elevated LDH: a sign of underlying tissue and/or liver damage?]
An increasing trend in LDH levels might suggest potential tissue or liver damage, warranting further investigation.
As per the available records, the patient’s general and gastroenterology surgeon issued a prescription on 2023-06-20, following the subtotal gastrectomy. The prescribed medications include B-Red (hydroxocobalamin), Mopride (mosapride citrate), Foliromin (ferrous sodium citrate), and Ulstop (famotidine). These medications were appropriately incorporated into the active medication list, and there were no identified reconciliation problems.
As per the records, our general and gastroenterological surgery department prescribed a 28-day course of B-Red (hydroxocobalamin), Mopride (mosapride citrate), Foliromin (ferrous sodium citrate), and Ulstop (famotidine) to this patient on 2023-06-20 due to his post subtotal gastrectomy status. These drugs have been correctly incorporated into the active medication list, and no reconciliation issues were identified.
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
Lab results on 2024-07-09 were within normal limits, and vital signs remained stable throughout the hospitalization. No medication discrepancies were identified.
[MedRec]
2024-06-26 SOAP General and Gastroenterological Surgery Zhang YaoRen
2024-06-14 ~ 2024-06-15 POMR General and Gastroenterological Surgery Zhang YaoRen
2024-06-12 SOAP General and Gastroenterological Surgery Zhang YaoRen
2024-06-03 SOAP General and Gastroenterological Surgery Zhang YaoRen
2024-05-13 SOAP General and Gastroenterological Surgery Zhang YaoRen
2024-02-26 SOAP General and Gastroenterological Surgery Zhang YaoRen
….-..-..
2017-03-20 SOAP General and Gastroenterological Surgery Zhang YaoRen
[ribociclib treatment schedule and neutropenia management]
Kisqali (ribociclib) was initiated on 2024-06-15 with a standard daily dose of 600mg. However, the prescribed regimen did not exactly match the recommended “21 days of use followed by a 7-day rest period to complete a 28-day treatment cycle,” as there was no clear 1-week rest period.
Ribociclib is associated with neutropenia (69% to 78%; grade 3: 46% to 55%; grade 4: 7% to 10%). The recommendations for managing neutropenia are:
Grade 3 neutropenia was noted on 2024-07-08 for the first time with ribociclib. It is recommended to interrupt ribociclib treatment until recovery to grade 2 or lower, then resume ribociclib at the same dose.
[lab data]
2023-11-28 HLA A-high 11:01
2023-11-28 HLA A-high 24:02
2023-11-28 HLA B-high 27:04
2023-11-28 HLA B-high 35:01
2023-11-28 HLA C-high 08:01
2023-11-28 HLA C-high 12:02
2023-11-28 HLA DQ-high 03:01
2023-11-28 HLA DQ-high 03:03
2023-11-28 HLA DR-high 12:01
2023-11-28 HLA DR-high 12:02
2023-09-13 FLT3-D835 (bone marrow) Undetectable
2023-09-11 CD2 NA
2023-09-11 CD3 3.4
2023-09-11 CD4 NA
2023-09-11 CD5 1.3
2023-09-11 CD7 98.6
2023-09-11 CD8 NA
2023-09-11 CD10 2.4
2023-09-11 CD11b 32.8
2023-09-11 CD13 94.7
2023-09-11 CD14 1.2
2023-09-11 CD15 NA
2023-09-11 CD16 0.76
2023-09-11 CD19 6.2
2023-09-11 CD19/kappa NA
2023-09-11 CD19/Lambda NA
2023-09-11 CD20 1.8
2023-09-11 CD23 NA
2023-09-11 CD25 NA
2023-09-11 CD33 85.2
2023-09-11 CD34 90.6
2023-09-11 CD38 NA
2023-09-11 CD56 0.4
2023-09-11 CD103 NA
2023-09-11 CD117 98.5
2023-09-11 CD138 NA
2023-09-11 FMC7 NA
2023-09-11 HLA-DR 99.1
2023-09-11 MPO NA
2023-09-11 TdT NA
2023-09-11 FLT3/ITD (bone marrow) Presence of mutation
2023-09-11 NPM1 (bone marrow) Undetectable
2023-09-11 LDH 276 U/L
2023-09-09 LDH 513 U/L
2023-09-05 LDH 2394 U/L
2023-09-04 HBsAg Nonreactive
2023-09-04 HBsAg (Value) 0.57 S/CO
2023-09-04 Anti-HBc Nonreactive
2023-09-04 Anti-HBc-Value 0.43 S/CO
2023-09-04 Anti-HCV Nonreactive
2023-09-04 Anti-HCV Value 0.14 S/CO
2023-09-03 LDH 1578 U/L
2023-08-31 Uric Acid 9.2 mg/dL
2023-08-31 LDH 1428 U/L
2023-08-31 WBC 351.74 x10^3/uL
2023-08-31 HGB 8.4 g/dL
2023-08-31 PLT 33 x10^3/uL
[exam findings]
[MedRec]
[consultation]
2023-10-18 Cardiology
2023-09-25 Reconstructive and Plastic Surgery
2023-09-01 Psychosomatic Medicine
[chemotherapy]
Rydapt (midostaurin 25mg) 2# Q12H - 2023-08-31 ~ 2023-11-07
In-hospital chemotherapy formulary (2023-02-20)
Cytarabine (conventional) - 2024-03-11 - https://www.uptodate.com/contents/cytarabine-conventional-drug-information
[U-Vanco dosage recommendations based on TDM results]
U-Vanco (vancomycin) 1000mg Q12H IVD is currently in use, with a TDM trough result of 9.6 µg/mL on 2024-07-07, below the recommended range of 10 to 15 µg/mL. It is advised to adjust the dosage to 1500mg Q12H or 1000mg Q8H to achieve the target range.
[HD-AraC (2nd session) & fever response (Tapimycin) - BP WNL (Sevikar hold considered)]
High-dose Ara-C, without anthracycline, was initiated on 2024-01-10. The 2nd session of this regimen was administered during this hospitalization.
A fever of 38.7’C on 2024-03-10, decreased to below 37’C today, 2024-03-11, after administration of Tapimycin (piperacillin, tazobactam).
BP since 2024-03-10, has been approximately 100/55 mmHg for 2 days. Sevikar (amlodipine, olmesartan) might be held for a few days and monitored before restarting.
[restarting posaconazole after discontinuation]
If posaconazole has been discontinued for several days (considered as washed out), it’s recommended to reintroduce the drug with a loading dose, specifically, 300 mg BID for two doses, then switch to a maintenance dose of 300 mg QD.
[leukopenia]
The patient was administered her initial dose of the cytarabine/daunorubicin (7+3) regimen on 2023-09-04. A week later, on 2023-09-11, her WBC count reached its lowest point at 0.84K/uL, after which an upward trend was noted.
2023-09-13 WBC 1.23 x10^3/uL 2023-09-11 WBC 0.84 x10^3/uL * 2023-09-10 WBC 1.02 x10^3/uL 2023-09-09 WBC 1.05 x10^3/uL 2023-09-08 WBC 1.09 x10^3/uL 2023-09-07 WBC 1.69 x10^3/uL 2023-09-06 WBC 8.35 x10^3/uL 2023-09-06 WBC 24.86 x10^3/uL 2023-09-05 WBC 247.70 x10^3/uL 2023-09-04 WBC 355.71 x10^3/uL 2023-09-03 WBC 366.64 x10^3/uL 2023-09-02 WBC 370.59 x10^3/uL 2023-09-02 WBC 361.09 x10^3/uL 2023-09-01 WBC 335.15 x10^3/uL
[thrombocytopenia]
Prior to receiving her first dose of the cytarabine/daunorubicin (7+3) regimen on 2023-09-04, the patient was already in a state of thrombocytopenia. Following the administration of chemotherapy, her platelet count (PLT) continued to decline, reaching 23K/uL on 2023-09-13, the day a blood transfusion was performed. Blood transfusions were also administered on the following dates: 2023-08-31, 2023-09-04, and 2023-09-08.
2023-09-13 PLT 23 x10^3/uL * 2023-09-11 PLT 54 x10^3/uL
2023-09-10 PLT 83 x10^3/uL
2023-09-09 PLT 124 x10^3/uL
2023-09-08 PLT 29 x10^3/uL
2023-09-07 PLT 52 x10^3/uL
2023-09-06 PLT 102 x10^3/uL
2023-09-06 PLT 125 x10^3/uL
2023-09-05 PLT 48 x10^3/uL
2023-09-04 PLT 69 x10^3/uL
2023-09-03 PLT 79 x10^3/uL
2023-09-02 PLT 75 x10^3/uL
2023-09-02 PLT 102 x10^3/uL
2023-09-01 PLT 111 x10^3/uL
For this admission, the patient was initially admitted through the emergency department and this is her first time seeking medical care at this hospital. There are no records available from PharmaCloud and no medication reconciliation issues have been identified.
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
[exam findings]
[MedRec]
[consultation]
[immunochemotherapy]
[lab data]
[exam findings]
[consultation]
TPN is a single-route administration method. Do not mix TPN medications with other drugs.”
Check BW QW5 and record I/O Q8H
Check one touch Q6H x2 days, if stable QD check
Please control BS < 200 mg/dl with RI sliding scale
QW1 check CBC/DC
QW1 check BUN. Cr. AST. ALT. T/D Bil. TG. ALP. rGT. Na. K. Cl. Ca. P. Mg. Zinc. Alb. Prealbumin or Transferrin
If TPN is not available, substitute with YF5 or D10W.
[surgical operation]
[chemotherapy]
[alternative needed: Avodart and tube-feeding issues]
Avodart (dutasteride) is not suitable for tube-feeding due to its formulation and potential adverse effects.
Urief (Silodosin 8mg) may be considered as an alternative and is currently in use.
Our urologist suggested (2024-06-29) that Oxbu (oxybutynin) could be given. This drug is designed as an extended release and can be halved, 0.5# BID may be an option.
[hepatic impairment and medication adjustment]
Liver damage is observed.
Amiorone (amiodarone) dosage adjustment is likely necessary in patients with significant hepatic impairment. No specific guidelines available. If hepatic enzymes exceed 3 times normal or double in a patient with an elevated baseline, consider reducing the dose or discontinuing amiodarone.
Use of Tramacet is not recommended (acetaminophen and tramadol undergo extensive hepatic metabolism).
2024-07-01 ALT 234 U/L
2024-06-28 ALT 405 U/L
2024-06-20 ALT 44 U/L
2024-07-01 AST 69 U/L
2024-06-28 AST 93 U/L
2024-06-20 AST 29 U/L
2024-07-01 Albumin (BCG) 2.9 g/dL
2024-06-28 Albumin (BCG) 3.4 g/dL
2024-07-01 r-GT 155 U/L
2024-06-03 r-GT 15 U/L
[exam findings]
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
[pain management]
Patient’s pain score on VAS was recorded as 5 on 2024-05-14. Please assess the adequacy of the current acetaminophen regimen for pain management.
[reconciliation]
Vital signs during this hospitalization are stable, and lab results on 2024-03-15 were unremarkable. No medication discrepancies are noted.
[check to see if the tachycardia is transient]
Lab results from 2024-01-31 were largely within normal ranges, and vital signs from the TPR panel remained within normal limits, with the exception of tachycardia, noted as HR 113 this morning. Should the tachycardia prove to be transient, proceeding with chemotherapy administration should not be deemed contraindicated.
[reconciliation]
This patient’s PhamaCloud record shows receipt of Epine (quetiapine 200mg) on 2023-12-15 from MOHW Bali Psychiatric Center. It has now been replaced with Otzuka (aripiprazole 15mg). Notably, both medications carry boxed warnings regarding increased mortality in elderly patients with dementia-related psychosis and potential suicidal thoughts or behavior. HIS5 records showed the patient’s 2 past consultations for suicidal thoughts scores of 2 or higher in the Psychosomatic Medicine department, close monitoring of potential suicidal ideation and behavior is strongly advised.
Additionally, our Psychosomatic Medicine specialist suggested lorazepam on 2023-12-30, yet it isn’t listed in the active medication list. It is recommended a check of the need for lorazepam.
[exam findings]
[MedRec]
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
[reconciliation]
The lab results from 2024-03-21 were generally within normal ranges, and the patient has maintained stable vital signs throughout the hospital stay.
There appears to be no contraindication to proceeding with the 5th session of FOLFOX chemotherapy, and no discrepancies in medication have been noted.
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemotherapy]
2024-06-24 - leucovorin 300mg/m2 660mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr
2024-06-03 - leucovorin 300mg/m2 660mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr
2024-05-17 - leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr
2024-04-25 - leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr
2024-04-01 - [leucovorin 400mg/m2 675mg NS 250mL 24 + fluorouracil 600mg/m2 1000mg NS 250mL 24hr] D1-2 (CCRT)
2024-03-08 - [leucovorin 400mg/m2 675mg NS 250mL 24 + fluorouracil 600mg/m2 1000mg NS 250mL 24hr] D1-2 (CCRT)
2024-02-15 - oxaliplatin 65mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 500mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (FOLFOX)
2024-02-01 - oxaliplatin 65mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 500mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (FOLFOX)
2024-01-15 - oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX)
2023-12-25 - oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX)
2023-12-04 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX)
2023-11-09 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX)
[enlarged lymph nodes on CT scan]
During this hospitalization, the patient’s blood glucose levels ranged from approximately 120 to 170 mg/dL, which is elevated but still acceptable. A CT scan on 2024-06-06 showed enlarged lymph nodes (up to 1.5 cm) in the mediastinum that were not previously described in earlier imaging and should be followed up. Except for pancytopenia, the lab results on 2024-06-24 were generally good. No medication discrepancies were identified.
[reconciliation]
Laboratory results from 2024-04-01 were grossly normal, revealing no evidences that would prevent the administration of chemotherapy as part of the CCRT plan. Additionally, a review of medications found no discrepancies.
[leukopenia trend with FOLFOX - CCRT considerations for immune function]
Leukopenia episodes (WBC < 4K/uL) were observed before and during the 6 administrations of the FOLFOX regimen from 2023-11-09 to 2024-02-16, with a slowly declining trend. Therefore, the influence of FOLFOX on leukopenia cannot be excluded.
LV + 5-FU for CCRT was administered on 2024-03-08 and 2024-03-09, but its effect is unlikely to have influenced the laboratory data on 2024-03-08. G-CSF has not been used since 2024-03-08. It is recommended to use G-CSF prior to CCRT if leukopenia is expected to compromise immunity.
Lab testing demonstrated a blood ferritin level of 18.9 ng/mL (2024-01-15), which falls below the normal range. Therefore, initiating oral iron supplementation may be beneficial to maintain adequate iron stores in this patient.
[reconciliation]
Leukopenia was identified in lab results on 2023-12-25. Consequently, the 5-FU bolus was omitted, and the Oxaliplatin dose was adjusted to 75mg/m2 from the originally planned 85mg/m2 for this chemotherapy session.
Despite vitamin B12 supplementation during this chemotherapy session, the patient’s mean corpuscular volume (MCV) on 2023-12-25 (79fL) remained below the lower limit of normal. This suggests mild microcytic anemia, potentially due to iron deficiency. Iron supplementation could therefore be helpful to raise the iron content of RBC, addressing this issue.
2023-12-04 HGB 11.5 g/dL < 13.5 and MCV 77.8 fL < 80. It is suggested to consider some vitamin and mineral supplements:
[exam findings] (not completed)
[immunochemotherapy]
[exam findings]
[immunochemotherapy]
[Improved CA199 Marker Suggests Potential Treatment Benefit
]
A negative RAS/BRAF test (2024-05-02) suggests potential benefit from EGFRi therapy.
CA199 Marker: While the CA199 tumor marker level showed an increase in May, it appears to have decreased somewhat recently.
Possible Treatment Effect: This decline could potentially indicate positive effects from the FOLFIRI plus Erbitux treatment regimen being administrated on 2024-05-09 and 2024-05-31.
Lab results on 2024-06-20 revealed mild hyperbilirubinemia. However, this finding is unlikely to prevent the patient from proceeding with the planned therapy.
No medication discrepancies were found.
[exam findings]
[MedRec]
[consultation]
2024-05-03 Infectious Disease
2024-04-29 Urology
2024-02-23 Urology
2024-02-01 Hemato-Oncology
2024-01-25 Colorectal Surgery
2024-01-24 Urology
[surgical operation]
[chemotherapy]
[Laboratory Results Favorable for Paclitaxel and Carboplatin Treatment]
Recent lab tests on 2024-06-20 show mostly normal results, including tumor markers CA125 and CA199. This suggests no significant obstacles to proceeding with the planned fifth cycle of paclitaxel and carboplatin treatment.
A review of medication records revealed no discrepancies.
[diagnosis] - 2023-03-21 admission note
[past history]
[allergy]
[family history]
[exam findings]
[surgical operation]
[immunochemotherapy]
[latest lab results and ongoing neuropathy prevention strategies]
No recent imaging updates are available since the last CT scan conducted on 2024-02-16.
The tumor marker CEA has continued to decrease, while CA199 has returned to normal levels. Other lab results from 2024-04-22, were also unremarkable.
B-Red (hydroxocobalamin) is currently being used as a prophylactic measure against chemotherapy-induced neuropathy. While there is evidence supporting the use of vitamin B12 for diabetic neuropathy, its efficacy in preventing chemotherapy-induced neuropathy remains inconclusive, according to the latest reviews in the UpToDate database.
2024-04-22 CEA 7.38 ng/mL
2024-04-09 CEA 7.89 ng/mL
2024-03-06 CEA 13.98 ng/mL
2024-04-22 CA199 23.71 U/mL
2024-04-09 CA199 22.84 U/mL
2024-03-06 CA199 23.57 U/mL
[reconciliation]
No inconsistencies in medication management were found during a detailed review of both the HIS5 and PharmaCloud databases.
The patient visited a local clinic on 2023-06-13 for her primary hypertension. She was prescribed Norvasc (amlodipine 5mg) to be taken once daily. This medication is now on the patient’s active medication list as a self-carried item with no reconciliation issues identified.
During this hospital stay, the patient has experienced vomiting 3 to 4 times while on metoclopramide. If the symptom persists, it may be worth considering prescribing prochlorperazine upon discharge.
On 2023-04-06, the patient’s lab data showed normal readings except for an elevated CEA of 6.38ng/mL. It seems that the patient is tolerating the treatment well.
On 2023-03-07, the patient was observed to have neutropenia. However, there was no administration of G-CSF and no reduction of the regimen dosage. Despite this, there have been no new episodes of neutropenia observed as of the present time.
2023-03-16 WBC 6.12 x10^3/uL
2023-03-07 WBC 2.92 x10^3/uL
2023-03-02 WBC 6.36 x10^3/uL
2023-02-14 WBC 4.11 x10^3/uL
2023-03-16 Neutrophil 66.7 %
2023-03-07 Neutrophil 39.1 %
2023-03-02 Neutrophil 67.7 %
2023-02-14 Neutrophil 63.0 %
According to today’s (2023-03-23) CT results, there is a significant regression of D-colon cancer, peritoneal seeding, lymph nodes, lung, and liver metastases. These findings suggest that the Avastin + FOLFIRI regimen is still effective.
The patient’s medical history indicates that her mother had DM. However, there is no record of the patient’s HbA1c test result in HIS 5, which is a recommended test to monitor and manage diabetes.
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
2024-05-15 ~ undergoing - Tamos (temozolomide) 260mg QDAC
2024-04-15 - irinotecan 120mg/m2 200mg D5W 250mL 1.5hr + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 400mg/m2 690mg NS 250mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRI)
2024-03-27 - irinotecan 120mg/m2 200mg D5W 250mL 1.5hr + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 400mg/m2 690mg NS 250mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRI)
2024-03-07 - irinotecan 120mg/m2 200mg D5W 250mL 1.5hr + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 400mg/m2 690mg NS 250mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRI)
2024-02-15 - oxaliplatin 85mg/m2 146mg D5W 250mL 2hr + leucovorin 400mg/m2 685mg NS 250mL 2hr + fluorouracil 400mg/m2 685mg NS 250mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX)
2024-01-31 - oxaliplatin 85mg/m2 146mg D5W 250mL 2hr + leucovorin 400mg/m2 685mg NS 250mL 2hr + fluorouracil 400mg/m2 685mg NS 250mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX)
2024-01-15 - oxaliplatin 85mg/m2 146mg D5W 250mL 2hr + leucovorin 400mg/m2 685mg NS 250mL 2hr + fluorouracil 400mg/m2 685mg NS 250mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX)
2023-12-29 - ………………………………….. leucovorin 400mg/m2 685mg NS 250mL 2hr …………………………………….. + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (Yang MuJun)
2023-08-31 ~ 2023-12-14 - Vepesid (etoposide 50mg) 1# QDAC PO
2023-08-08 - [etoposide 80mg/m2 135mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 500mL 3hr] D1-3 (Xia HeXiong)
2023-07-19 - [etoposide 80mg/m2 135mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 500mL 3hr] D1-3 (Xia HeXiong)
2023-06-29 - [etoposide 80mg/m2 135mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 500mL 3hr] D1-3 (Xia HeXiong)
2023-06-08 - [etoposide 80mg/m2 135mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 500mL 3hr] D1-3 (Xia HeXiong)
2023-05-16 - [etoposide 80mg/m2 135mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 500mL 3hr] D1-3 (Xia HeXiong)
2023-04-20 - [etoposide 80mg/m2 135mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 500mL 3hr] D1-3 (Xia HeXiong)
2022-03-22 - [etoposide 100mg/m2 160mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 200mL 3hr] D1-3 (You ZhiQin)
2022-03-01 - [etoposide 100mg/m2 160mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 200mL 3hr] D1-3 (You ZhiQin)
2022-02-08 - [etoposide 100mg/m2 160mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 200mL 3hr] D1-3 (You ZhiQin)
2022-01-12 - [etoposide 100mg/m2 160mg NS 500mL 2hr + cisplatin 25mg/m2 40mg NS 200mL 3hr] D1-3 (You ZhiQin)
[initiation of temozolomide for lung metastases progression]
On 2024-05-16, a CT scan revealed progression of lung metastases, leading to the initiation of Tamos (temozolomide) at 260 mg QDAC. Lab results on 2024-06-18 were grossly normal. No medication discrepancies were identified after reviewing HIS5 and PharmaCloud.
[neutropenia]
(not used) The patient’s last chemotherapy treatment before the lab result on 2023-12-28 was on 2023-08-08. Due to the long time interval between the treatment and the neutropenia episode, it is difficult to conclude with certainty that the neutropenia was directly caused by the previous chemotherapy.
A 28-day supply of oral etoposide was prescribed on 2023-11-16. This medication carries a known risk of leukopenia, with an incidence ranging from 60% to 91%. The severity can reach grade 4 in 3% to 17% of cases, with the nadir typically occurring 7 to 14 days after administration and recovery expected by day 20.
In response to the patient’s leukopenia, two days of Granocyte (lenograstim 250ug) were promptly administered.
The patient recently renewed his repeat prescription for Diovan (valsartan) for a 28-day supply on 2023-08-07. This medication has been added to the active list of medications without an identified reconciliation problem.
According to the PharmaCloud database, this patient regularly refills his prescription for Diovan (valsartan) to treat his primary hypertension. This medication was correctly added to the active formulary and no issues were identified during the medication reconciliation process.
According to PharmaCloud data, this patient has only sought medical treatment at our hospital. No issues with medication reconciliation were identified.
The latest lab data, collected on 2023-06-06, shows largely normal results and readings from the TPR panel are stable. There are no issues with the current prescription.
The patient’s prostate cancer was pathologically confirmed as small cell neuroendocrine carcinoma on 2021-12-01. Given the histologic characteristics of small cell components, the regimens used for small cell lung cancer (SCLC) are considered preferable. Therefore, the patient received both cisplatin (25mg/m2) and etoposide (100mg/m2) on days 1 to 3 for 4 cycles in the first quarter of 2022. The same regimen was restarted (etoposide at 80mg/m2) on 2023-04-20 due to a lung wedge biopsy performed on 2023-03-17 that indicated metastatic small cell neuroendocrine carcinoma. The treatment is currently ongoing.
There were no notable abnormalities found in the TPR panel and lab data from 2023-05-16. In addition, no medication reconciliation issues were identified.
{triple negative breast cancer}
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
docetaxel 75mg/m2 and carboplatin AUC 6, cycled every 21 days x 4-6 cycles, preoperative setting only - NCCN 2022-06-21
PREOPERATIVE/ADJUVANT THERAPY REGIMENS - HER2-Negativeb (Breast Cancer NCCN Guidelines 20220621 Version 4.2022, BINV-L 1 OF 9, p55)
According to PharmaCloud records, the patient has only been seen at our hospital for the past three months. After reviewing the HIS5 records, no medication reconciliation issues were identified.
[Trodelvy (sacituzumab govitecan)]
Trodelvy (sacituzumab govitecan) has received approval from the TFDA and is prescribed for two specific indications:
However, it’s important to note that this medication is not currently covered by the NHI program. Therefore, it may pose a financial burden for patients who are economically disadvantaged.
{gastric cancer, T1a pN3a (6/32) cM0, pStage: IIB, s/p Op on 20220414}
[exam findings] (not completed)
[MedRec]
[consultation]
[surgical operation]
[radiotherapy]
[chemoimmunotherapy]
COXAL01 Oxalip package insert - 2024-06-19
Chemotherapy regimens for locally advanced, potentially resectable gastric or gastro-esophageal junction adenocarcinoma: Perioperative docetaxel, oxaliplatin, fluorouracil, and leucovorin (FLOT4) - 2024-05-24 - https://www.uptodate.com/contents/image?imageKey=ONC%2F120512
[Neutropenia Resolved, Leukocytosis Developed - FLOT Chemo Planned]
The neutropenia reached its nadir on 2024-05-20. There is no longer any evidence of neutropenia.
Conversely, leukocytosis has now developed. The second session of FLOT chemotherapy is scheduled for 2024-05-24.
2024-05-23 Neutrophil 70.8 %
2024-05-20 Neutrophil 19.6 % ***
2024-05-16 Neutrophil 80.4 %
2024-05-23 WBC 20.07 x10^3/uL
2024-05-20 WBC 1.56 x10^3/uL ***
2024-05-16 WBC 2.96 x10^3/uL
2024-05-13 WBC 8.18 x10^3/uL
2024-05-09 WBC 9.57 x10^3/uL
2024-05-07 WBC 9.30 x10^3/uL
2024-04-29 WBC 7.95 x10^3/uL
2024-04-23 WBC 8.23 x10^3/uL
The serum ALT level trended upward.
The use of oxaliplatin has been associated with an increase in ALT levels (incidence of 36% with monotherapy)
There is no need to adjust the dosage of the components in the current regimen of FOLFOX.
The addition of pyridostigmine as a self-carried item is recommended for the patient with myasthenia gravis since this medication has no known heavy interactions with the active prescription.
[exam findings]
[MedRec]
[consultation]
[surgical operation]
[chemotherapy]
Lab readings on 2024-06-17 showed grossly normal values and no medication discrepancies identified after review of HIS5 and PharmaCloud database.
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
[mild macrocytosis observed despite vitamin B12 supplementation]
The lab results on 2024-06-17 were grossly normal and did not pose an contraindication to the current FOLFOX therapy.
Iron storage appears adequate, as evidenced by normal ferritin levels. Mild macrocytosis is noted, and Kentamin, which includes Vitamin B12, is currently in use. If macrocytosis persists, the use of B-Red (hydroxocobalamin) and/or folate might be further considered.
2024-06-17 HGB 10.4 g/dL
2024-06-17 MCV 103.4 fL
2024-06-04 Ferritin 76.6 ng/mL
2024-04-30 Ferritin 72.9 ng/mL
[exam findings]
[improving kidney function, but high Brosym dose needed adjustment]
The patient’s kidney function is showing signs of improvement based on recent eGFR lab results. However, her kidney function is still far from normal.
According to the Sanford Guide, sulbactam-cefoperazone dosage needs adjustment in patients with creatinine clearance below 30 mL/min to account for reduced sulbactam clearance.
Currently, the patient is receiving Brosym 4 grams Q12H, which is double the recommended dose. It is recommended adjusting the Brosym dosage to 2 grams Q12H
[NCCN guidelines for ccRCC treatment and NHI reimbursement policies]
This patient was recently diagnosed with grade 2 clear cell renal cell carcinoma, T2aN1M1, stage IV, with right iliac bone metastasis.
According to the NCCN guidelines (version 2024-05-30), preferred regimens for favorable-risk patients include:
The NHI reimbursement policy for each of the drugs in the regimens is as follows:
[MedRec]
2024-06-14 ~ 2024-06-15 POMR General and Gastroenterological Surgery Zhang YaoRen
2024-05-29 SOAP General and Gastrointestinal Surgery Chen JiaHui
2024-05-23 ~ 2024-05-25 POMR General and Gastroenterological Surgery Zhang YaoRen
2024-05-05 ~ 2024-05-07 POMR General and Gastroenterological Surgery Zhang YaoRen
2024-04-17 ~ 2024-04-19 POMR General and Gastroenterological Surgery Zhang YaoRen
2024-04-15 SOAP General and Gastroenterological Surgery Zhang YaoRen
2024-04-08 SOAP General and Gastroenterological Surgery Zhang YaoRen
2024-04-01 ~ 2024-04-02 POMR General and Gastroenterological Surgery Zhang YaoRen
2024-03-19 SOAP Surgical Emergency Wu MengYu
2024-03-15 ~ 2024-03-17 POMR General and Gastroenterological Surgery Zhang YaoRen
2024-01-01 ~ 2024-01-03 POMR General and Gastroenterological Surgery Zhang YaoRen
2023-11-19 ~ 2023-11-21 POMR General and Gastroenterological Surgery Zhang YaoRen
[chemotherapy]
Talsenna (talazoparib 0.25mg) 2# QDCC - 2024-06-14 ~ 2024-06-24 Talsenna (talazoparib 0.25mg) 3# QDCC - 2024-05-23 ~ 2024-06-02 Talsenna (talazoparib 0.25mg) 4# QDCC - 2024-05-06 ~ 2024-05-16 Talsenna (talazoparib 0.25mg) 4# QDCC - 2024-04-18 ~ 2024-04-26 Talsenna (talazoparib 0.25mg) 3# QDCC - 2024-03-16 ~ 2024-06-02 Talsenna (talazoparib 0.25mg) 4# QDCC - 2024-01-01 ~ 2024-03-15
[potential need for further supplementation beyond iron]
In the past half-month, there has been a noticeable decline in WBC and HGB levels. During this period, Talsenna (talazoparib) was already being administered at a reduced dose of 0.75 mg daily. Due to the continued occurrence of leukopenia and anemia, the dosage was further reduced to 0.5 mg daily starting from 2024-06-14.
2024-06-14 WBC 1.64 x10^3/uL
2024-05-23 WBC 2.38 x10^3/uL
2024-05-05 WBC 3.80 x10^3/uL
2024-06-14 HGB 7.4 g/dL
2024-05-23 HGB 10.9 g/dL
2024-05-05 HGB 12.3 g/dL
Additionally, despite several months of Foliromin (ferrous sodium citrate) supplementation, the concurrent occurrence of macrocytosis suggests that the anemia may not be solely due to iron deficiency. It is recommended to further assess iron storage and/or Vitamin B12 (cobalamin) and folate levels to determine if supplementation of the latter two is needed.
[neutropenia (ANC 576) - Talsenna withheld, consider restart at 0.5mg daily if ANC > 1.5K]
Talsenna (talazoparib) was last prescribed at a reduced dose of 0.75mg daily on 2024-03-17 for a 15-day course, ending on 2024-04-01.
Recent lab results, however, revealed grade 3 neutropenia with an ANC of 576/uL.
It is recommended to hold Talsenna therapy until the neutrophil count recovers above 1,500/uL. If continuing treatment is deemed necessary, resuming therapy at a further reduced dose of 0.5mg daily should be considered.
[guidelines for talazoparib dose reduction in case of low WBC]
The patient has been receiving the PARP inhibitor Talsenna (talazoparib) since the beginning of 2024 and continues to do so.
The regimen involves a standard dose of talazoparib, 1mg once daily.
2024-03-15 WBC 1.78 x10^3/uL
2024-02-23 WBC 3.49 x10^3/uL
2024-02-07 WBC 2.35 x10^3/uL
2024-02-01 WBC 4.53 x10^3/uL
2024-03-15 Neutrophil 66.3 %
2024-02-23 Neutrophil 69.9 %
2024-02-07 Neutrophil 70.6 %
2024-02-01 Neutrophil 72.8 %
As of the lab data on 2024-03-15, the patient’s renal and liver functions were within normal ranges.
Talazoparib is known to have a 68% incidence of neutropenia, with 17% of cases being grade 3 and 3% grade 4.
On 2024-03-15, the ANC was calculated to be 1.18 K/uL, indicating no need for dose reduction at this time. However, should the WBC count drop below 1K/uL, it is advisable to resume therapy at a reduced dose of 0.75mg daily.
The dosage of the medication was adjusted to 0.75mg once daily during the hospitalization on 2024-03-16.
[lab data]
2023-11-13 HBV-DNA-PCR Target Not Detected IU/mL
2023-11-08 HBsAg Nonreactive
2023-11-08 HBsAg (Value) 0.34 S/CO
2023-11-08 Anti-HBs 538.50 mIU/mL
2023-11-08 Anti-HBc Reactive
2023-11-08 Anti-HBc-Value 6.16 S/CO
2023-11-08 Anti-HCV Nonreactive
2023-11-08 Anti-HCV Value 0.11 S/CO
[exam findings]
[MedRec]
[immunochemotherapy]
[expected dyspnea improvement post-drainage; monitoring calcium levels for tachyphylaxis]
On the afternoon of 2024-06-17, a right-sided pig-tail drainage was performed via the 7th intercostal space at the posterior mid-axillary line, resulting in the smooth drainage of serosanguinous fluid. This procedure is expected to improve dyspnea.
Miacalcic (calcitonin) 100 units Q8H was initiated on 2024-06-17 for hypercalcemia. Please closely monitor calcium levels for potential tachyphylaxis.
[reconciliation]
Following lab findings on 2023-12-25 (CRP 11.5 mg/dL and erect CXR demonstrating right lower lung consolidation and blunted costophrenic angles), Brosym (cefoperazone/sulbactam) was initiated. The patient’s fever has favorably responded, decreasing to 37’C as of 2023-12-26. No medication discrepancies were noted.
This patient is currently undergoing the R-COP regimen and is also taking Vemlidy (tenofovir alafenamide) due to being anti-HBc positive. The patient’s vital signs are stable, and no discrepancies in medication have been identified.
[MedRec]
[radiotherapy]
[immunochemotherapy]
[comparing neutropenia rates: eribulin vs. bevacizumab]
Eribulin is more likely to be a major factor causing neutropenia than bevacizumab
Eribulin is associated with neutropenia incidence rates of 63% to 82%, with grades ≥3 occurring in 12% to 57% of cases. In contrast, bevacizumab is associated with neutropenia in 12% of cases, with grades 3/4 occurring in 8% to 21% of cases.
When chemotherapy-induced neutropenia develops, the use of G-CSF might be beneficial.
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
[decline in liver and kidney function; managing AKI and hyperuricemia; Euricon and hydration requirements]
The patient’s liver and kidney function appear to be declining, as evidenced by increasing bilirubin levels and decreasing eGFR, with AKI confirmed by an increase in serum creatinine by ≥0.3 mg/dL within 48 hours, meeting the KDIGO guidelines for AKI.
2024-06-13 Bilirubin total 2.16 mg/dL
2024-06-11 Bilirubin total 1.75 mg/dL
2024-05-06 Bilirubin total 0.88 mg/dL
2024-06-13 Creatinine 2.03 mg/dL
2024-06-11 Creatinine 1.69 mg/dL
2024-06-13 eGFR 35.10 ml/min/1.73m^2
2024-06-11 eGFR 43.37 ml/min/1.73m^2
2024-05-15 eGFR 65.01 ml/min/1.73m^2
2024-05-06 eGFR 73.49 ml/min/1.73m^2
Euricon (benzbromarone) has been prescribed for hyperuricemia. When taking this drug, it is important to drink plenty of water to help excrete uric acid in the urine. However, if the patient has decreased urine output, this medication may not be suitable, and its use is not recommended for patients with an eGFR <30 mL/minute (EULAR Richette 2017). As an alternative, Feburic (febuxostat) is recommended, with the dose limited to 40 mg daily for patients with a CrCl of 15-29 mL/min according to the package insert.
[evaluating treatment options for edema and hyperbilirubinemia]
Given the patient’s 3+ pitting edema in the limbs and worsening hyperbilirubinemia, considering the administration of furosemide and Uliden (ursodeoxycholic acid) may be appropriate if there are no contraindications.
[renal function decline: Zulitor adjusted, caution advised for Pamisol]
The patient’s serum creatinine levels remained around 1mg/dL from 2023-11 to 2024-01. However, starting from 2024-02, the levels increased to approximately 1.5mg/dL, with the latest eGFR being 47. Consequently, the dosage of Zulitor (pitavastatin) has been adjusted in accordance with the patient’s renal function status.
If there are plans to use Pamisol (pamidronate) for the patient, it’s important to maintain good renal function, as Pamisol is not recommended for patients with osteolytic bone metastases if their CrCl < 30 mL/minute or their SCr > mg/dL.
[lab data]
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
[adjusted oxaliplatin dose in FOLFOX]
There appears to be a slow upward trend in serum creatinine. The oxaliplatin in the FOLFOX regimen has been reduced to 100 mg during this hospitalization. Oral potassium supplementation is being used for hypokalemia, and Vemlidy (tenofovir alafenamide) is administered for reactive Anti-HBc (2024-02-22). No medication discrepancies were identified.
2024-06-13 Creatinine 1.96 mg/dL
2024-06-05 Creatinine 1.91 mg/dL
2024-05-27 Creatinine 1.88 mg/dL
2024-05-14 Creatinine 1.83 mg/dL
2024-05-09 Creatinine 1.47 mg/dL
2024-06-13 K (Potassium) 3.1 mmol/L
[consistent creatinine levels despite oxaliplatin, hydroxocobalamin effect on hemoglobin stability]
B-Red (hydroxocobalamin) was administered intermittently, approximately biweekly to monthly, stabilizing hemoglobin levels at around 10 ± 0.5 g/dL over the past two months without significant fluctuations.
Serum creatinine levels have consistently been maintained at approximately 1.5 mg/dL during this period, indicating no renal deterioration attributable to oxaliplatin.
Blood glucose levels were recorded at 250 and 184 mg/dL, slightly elevated but remain manageable.
[reconciliation]
Oxaliplatin dosage adjustments are advised for patients with CrCl < 30. Given the lab results from 2024-04-01 showing eGFR > 50, there is currently no necessity for dosage modification.
[FOLFOX begins for post-gastrectomy patient]
The patient was admitted on 2024-03-11 for his first session of FOLFOX therapy.
B-Red (hydroxocobalamin) was administered on 2024-03-12 for this post-gastrectomy patient. The active medication list currently includes only one antiglycemic agent, Dibose (acarbose). This follows the discontinuation of several medications: Amepiride (glimepiride), Forxiga (dapagliflozin), Crestor (rosuvastatin), and Sevikar (amlodipine, olmesartan). While there is no current elevated BP, the blood sugar readings of 263 mg/dL on 2024-03-11 and 229 mg/dL on 2024-03-12 could potentially benefit from further management.
[lab data]
[exam findings]
2024-05-22 Patho - liver biopsy needle/wedge
2024-05-22 Patho - duodenum biopsy
2024-05-21 PTCD (percutaneous transhepatic cholangial drainage)
2024-05-21 EGD
2024-05-21 SONO - abdomen
2024-05-19 CT - abdomen
[MedRec]
[MultiTeam]
[continuous decline in elevated bilirubin levels, potential need for intensive nutritional intervention]
Although bilirubin levels are still above the reference range, they have shown a continuous decline, with Uliden (ursodeoxycholic acid) currently in use. Baraclude (entecavir) is being appropriately administered following the 2024-05-20 lab results indicating reactive Anti-HBc.
2024-06-12 Bilirubin total 1.97 mg/dL
2024-06-06 Bilirubin total 2.20 mg/dL
2024-06-03 Bilirubin total 2.77 mg/dL
2024-05-30 Bilirubin total 3.44 mg/dL
2024-05-27 Bilirubin total 4.50 mg/dL
2024-05-22 Bilirubin total 9.70 mg/dL
2024-05-19 Bilirubin total 15.30 mg/dL
2024-06-12 Bilirubin direct 0.96 mg/dL
2024-06-06 Bilirubin direct 1.15 mg/dL
2024-05-30 Bilirubin direct 1.76 mg/dL
2024-05-19 Bilirubin direct 9.59 mg/dL
2024-06-12 DBI/TBI 48.73 %
2024-06-06 DBI/TBI 52.27 %
2024-05-30 DBI/TBI 51.16 %
2024-05-19 DBI/TBI 62.68 %
The patient’s weight has decreased from 49.4 kg on 2024-05-19 to 46.7 kg on 2024-06-13. Currently, the patient is receiving Bfluid amino acids supplementation and Megest (megestrol). If the weight loss continues, intensive nutritional intervention might be necessary.
[exam findings]
[MedRec]
[surgical operation]
[chemotherapy]
[positive CA125 response to chemotherapy]
The marker CA125 has been steadily decreasing since the initiation of chemotherapy on 2024-04-19, which is a positive sign.
The remaining lab data were unremarkable, with no contraindicating results to prevent proceeding with the new session of chemotherapy scheduled for today.
[optional addition of silymarin for elevated liver enzymes]
The first two sessions of the TP regimen were administered on 2024-04-19 and 2024-05-21. Following the administration, there was a mild elevation remaining in liver enzymes AST and ALT. Adding BaoGan (silymarin) might be considered as an optional supplement.
2024-05-20 AST 40 U/L
2024-05-02 AST 44 U/L
2024-04-25 AST 54 U/L
2024-04-18 AST 38 U/L
2024-05-20 ALT 45 U/L
2024-05-02 ALT 42 U/L
2024-04-25 ALT 56 U/L
2024-04-18 ALT 28 U/L
[exam findings]
[MedRec]
[consultation]
[radiotherapy]
[chemotherapy]
[MRI shows stable disease under PF regimen]
The current PF regimen has kept the disease stable, as confirmed by MRI on 2024-05-24. The eGFR of 48 on 2024-06-11 remains around 50, with no significant deterioration observed. Other lab results were unremarkable, and no medication discrepancies were found.
[stable kidney function and well-managed comorbidities]
The moderately impaired renal function has remained stable over the past three months.
The underlying conditions of hypertension, hyperglycemia, hyperuricemia, and positive anti-HBc are currently managed with Concor (bisoprolol), Exforge (amlodipine, valsartan), Dibose (acarbose), Galvus Met (vildagliptin, metformin), Feburic (febuxostat), and Vemlidy (tenofovir alafenamide) effectively, with no medication discrepancies identified.
It may be beneficial to repeat the nasopharyngeal MRI. (last 2024-01-24)
[persistent anemia despite chemo (prior CCRT ended dec 2023): possible other contributing factors]
Despite undergoing chemotherapy during this hospitalization, the prior CCRT had already concluded by the end of Dec 2023. However, anemia persists, suggesting that factors other than chemotherapy might be contributing to the patient’s ongoing anemia.
For example, gastrointestinal bleeding?
2024-03-20 Stool OB 1+
2024-03-20 HGB 8.7 g/dL 2024-01-29 HGB 9.1 g/dL 2024-01-03 HGB 9.1 g/dL 2023-12-20 HGB 9.7 g/dL 2023-12-06 HGB 10.2 g/dL
[Kidney function fluctuates downward]
Lab:
2023-11-17 eGFR 60.17 ml/min/1.73m^2
2023-11-06 eGFR 80.68 ml/min/1.73m^2
2023-11-17 BUN 44 mg/dL
2023-11-06 BUN 19 mg/dL
It is recommended that 50% of the usual total daily dose of metoclopramide be given if CrCl falls between 10 and 60 mL/minute.
[decline in renal function over the last month]
The patient’s renal function has deteriorated over the past 30 days.
2023-10-26 BUN 60 mg/dL
2023-10-11 BUN 48 mg/dL
2023-10-05 BUN 34 mg/dL
2023-09-25 BUN 19 mg/dL
2023-10-26 Creatinine 1.12 mg/dL
2023-10-11 Creatinine 0.99 mg/dL
2023-10-05 Creatinine 0.92 mg/dL
2023-09-25 Creatinine 0.85 mg/dL
Carboplatin is associated with decreased creatinine clearance (27%), increased blood urea nitrogen (14% to 22%)
Valsartan may be associated with increased serum creatinine and/or acute kidney injury. Increases in serum creatinine secondary to angiotensin receptor blockers usually stabilize within 20% to 30% from baseline and are expected; additional increases may indicate renal artery stenosis or volume depletion.
Adverse events reported post-marketing include interstitial nephritis with famotidine, acute interstitial nephritis with amlodipine, and acute kidney injury, Fanconi syndrome, proximal tubular nephropathy, and renal tubular necrosis with tenofovir alafenamide.
After reviewing the PharmaCloud and HIS5 records for this admission, no medication reconciliation issues were identified.
No medication reconciliation issues were found when this admission after reviewing PharmaCloud and HIS5.
[exam findings]
[check for blood clots, infection, heart and liver issues]
Leukocytosis with a left shift, elevated fibrinogen, D-dimer, NT-proBNP, and prolonged PT were observed.
Please check for the presence of blood clots, infection or inflammatory conditions, heart problems (inferior infarct and possible anterolateral infarct on 2024-06-11 ECG), and liver issues (multiple liver tumors and ascites as indicated by the 2024-06-11 CT scan).
The PharmaCloud database shows recent refills of Concor (bisoprolol), Blopress (candesartan), Zulitor (pitavastatin), and Zcough (benzonatate). These medications are now on the active medication list with no discrepancies found.
Brosym (cefoperazone, sulbactam) is currently being used empirically; no culture results are available yet.
[lab data]
2023-07-18 CA-199 (NM) 52.608 U/ml
2023-07-04 CA-199 (NM) 38.491 U/ml
2023-06-09 CA-199 (NM) 39.33 U/ml
2022-05-26 CA-199 53.04 U/mL
2023-06-09 HBsAg (NM) Negative
2023-06-09 HBsAg Value (NM) 0.373
2023-06-09 Anti-HCV (NM) Negative
2023-06-09 Anti-HCV Value (NM) 0.042
2023-06-09 Anti-HBc (NM) Positive
2023-06-09 Anti-HBc Value (NM) 0.009
2023-06-09 Anti-HBs (NM) Negative
2023-06-09 Anti-HBs value (NM) 4.06 mIU/mL
2022-05-26 HBsAg Nonreactive
2022-05-26 HBsAg (Value) 0.63 S/CO
2022-05-26 Anti-HCV Nonreactive
2022-05-26 Anti-HCV Value 0.08 S/CO
[exam findings]
[MedRec]
[consultation]
[chemotherapy]
[evaluating potential causes of hyponatremia]
Hyponatremia has been noted for several days. There is no report linking gemcitabine to hyponatremia. Currently, 3% NaCl is being administered.
No evidence of hyperglycemia is present (random glucose on 2024-06-08 was 92 mg/dL), making hyperglycemia-induced hyponatremia unlikely.
No evidence of jaundice (2024-06-11), hyperlipidemia (2024-03-08), or hyperproteinemia (2024-06-07) is present, making pseudohyponatremia unlikely.
No thiazide diuretics are in use, and eGFR is not impaired (2024-06-11). Hypotonic hyponatremia with edema and/or ascites might be suspected (2024-06-04 CXR showed bilateral pleural effusions, 2024-05-21 CT showed small ascites). Recent urine osmolality data is not available; it might be beneficial to check for low effective arterial blood volume.
[medication reconciliation]
This patient just refilled Betmiga (mirabegron) on 2023-07-10 for her urinary incontinence for a 28-day valid duration at Far Eastern Hospital, this drug is not included in the active medication list, please confirm if this drug is not necessary for the patient’s current condition.
[poor medication compliance, non-adherence to medication regimen]
The 2023-07-26 progress note states, “The patient requested to self-administer her medications, adjusting them based on her daily condition. She expressed concern about receiving medications from nurses. The nurse practitioner educated her about the safety of medication administration by the nursing team, but the patient was unable to accept it. As a result, the patient’s outpatient medication was discontinued”.
On 2023-07-26, I visited the patient and her caregiver at approximately 11:00 am to address the concerns raised in the progress note regarding the patient’s medication compliance.
The patient said she is a member of TzuChi and was diagnosed with suspected cholangiocarcinoma in 2022-05 and subsequently treated at ShinKong Hospital. During the visit, I found that the patient tends to be selective in taking prescribed medications, believing that certain medications are more effective and should be taken more, while she perceives little efficacy from other prescribed medications. In addition, the patient mentioned that she does not always take her prescribed painkiller.
I have tried to help the patient understand the importance of adhering to the prescribed medication regimen. However, it appears that the patient still holds strong personal beliefs regarding medication, which may lead to inaccurate assessments of treatment effectiveness.
Regarding the issue of low sodium levels, I advised the patient to increase her salt intake, the patient attributed this to the caregiver’s cooking, as she felt that the meals were not seasoned enough. However, upon further discussion with the nurses, the caregiver mentioned that she already added an adequate amount of salt to the meals.
[exam findings]
2024-05-19, -05-07, -04-26, -04-24 CXR erect
2024-04-30 SONO - abdomen
2024-04-25 PD-L1 (28.8)
2024-04-19 Surgical pathology Level IV
2024-04-19 Patho - stomach biopsy
2024-04-19 EGD
2024-04-17 PET
2024-04-16 Upper GI series
2024-04-10 T-tube cholangiography
2024-04-08 Patho - pleural/pericardial biopsy
2024-04-03 CT - chest
2024-04-02 MRI - pancreas
2024-04-02 Percutaneous gall bladder drainage, PTGBD
2024-03-28 Patho - stomach biopsy
2024-03-23 CT - abdomen
2024-03-22 Upper GI & Small Intestine
2024-03-22 SONO - abdomen
2024-03-15 Miniprobe Endoscopic Ultrasound
[MedRec]
[consultation]
[surgical operation]
[immunochemotherapy]
[potential need for intensive nutrition in cachexia]
The patient’s weight has decreased by 16% within one month (from 48.9 kg on 2024-05-07 to 41.1 kg on 2024-06-11), indicating evident cachexia. Currently, Megest (megestrol) is being administered. If the weight loss continues, more intensive nutritional intervention might be necessary.
CA-199 has shown a slight increase over the past month, while bilirubin levels have remained stable under BaoGan (silymarin) and Uliden (ursodeoxycholic acid). No medication discrepancies have been identified.
[first dose of nivolumab and FOLFOX administered, tumor markers increasing despite treatment; hyperbilirubinemia managed with ursodeoxycholic acid]
Possible GI-originated adenocarcinoma biopsied from the lung was pathologically proven, and PD-L1 (28.8) showed CPS < 1. The first dose of nivolumab plus FOLFOX was administered on 2024-04-22. The readings of tumor markers CEA and CA199 have continued to increase until early-mid May.
2024-05-10 CA-199 (NM) 128.115 U/ml
2024-03-14 CA199 94.990 U/mL
2024-05-10 CEA (NM) 3.451 ng/ml
2024-03-14 CEA 2.850 ng/mL
The hyperbilirubinemia was primarily due to elevated conjugated bilirubin. Currently, Uliden (ursodeoxycholic acid) is in use, and the direct bilirubin readings appear to be decreasing.
No medication discrepancies were found after reviewing PharmaCloud and HIS5.
[exam findings]
[MedRec]
[surgical operation]
[radiotherapy]
[chemotherapy]
Why give Taxol (Paxel) before carboplatin? - 2024-02-26 - https://www.drugs.com/medical-answers/give-taxol-paxil-before-carboplatin-3562689/
Medically reviewed by Carmen Pope, BPharm. Last updated on Oct 2, 2023.
Official answer by Drugs.com
Why is Taxol and carboplatin used together?
How effective is Taxol and carboplatin?
[previous neutropenia (paclitaxel/carboplatin) - risk of recurrence]
The patient experienced an episode of neutropenia 1-2 weeks following the last administration of paclitaxel and carboplatin on 2024-02-26. There is a risk of recurrent neutropenia with the 2nd administration of these medications.
No repeat prescriptions have been issued by any healthcare provider other than ours according the the PharmaCloud database. Furthermore, the medications prescribed by our cardiologist on 2024-02-01 have been incorporated into the active medication list without any discrepancies.
The patient’s vital signs have remained stable throughout this hospital stay, and laboratory results from 2024-02-26 did not reveal any significant findings. There is no evidence to suggest any contraindications for the administration of the paclitaxel and carboplatin regimen.
[exam findings]
[MedRec]
[immunochemotherapy]
This patient with Small cell B-cell lymphoma was treated with a total of six cycles of R-COP regimen from 2021-10 to 2022-03. However, during regular CT follow-up on 2022-11-25, progression of lymphadenopathy was observed in the mesenteric and paraaortic regions. As a result, the patient was rechallenged with R-COP from 2022-12 onwards.
The lab results from 2023-03-01 indicated that there were no notable abnormalities in the patient’s liver and kidney functions or blood cell counts. And the TPR panel revealed that the patient’s vital signs and blood pressure were stable.
Entecavir is prescribed to suppress the replication of the hepatitis B virus with no issue.
[exam findings]
[consultation]
[chemotherapy]
[Chemotherapy-Induced Anemia]
Lab:
Docetaxel and Potential Contribution to Anemia
The patient received Taxotere (docetaxel) on 2024-05-17 and 2024-05-24).
While anemia was already present before these treatments, docetaxel is known to have a high incidence of anemia (65% to 97%, with 8% to 9% reaching grades 3/4). Therefore, it’s possible that the chemotherapy may have worsened (exacerbated) the existing anemia.
Management of Severe Chemotherapy-Induced Anemia
In cases of severe anemia caused by chemotherapy, leukocyte-reduced packed red blood cell (LPRBC) transfusions may be considered. (A blood transfusion was performed on 2024-05-27).)
[Trodelvy as alternative for severe anemia if current regimen not tolerated anymore]
If the treatment with docetaxel causes recurrent and severe anemia in this patient, it may be necessary to consider adjusting the regimen. In such a case, Trodelvy (sacituzumab govitecan) might be considered. The NHI coverage criteria for this drug are as follows:
[exam findings]
[MedRec]
[immunochemotherapy]
[Patient Experiences Severe Symptoms of Anorexia, Cough, and Dyspnea]
The patient is reported to have symptoms of loss of appetite (anorexia), cough, and difficulty breathing (dyspnea), all of which are classified as Grade 3 (severe). It is noted that the patient’s weight reached a recorded high of 78.8 kg on 2023-11-06, but then fluctuated with more decreases than increases, reaching a low of 60.5 kg on 2024-04-12. Recently, on 2024-05-24, the weight has risen slightly to 66.1 kg. These weight changes during this period may be influenced by the patient’s swallowing difficulties, which could be a possible cause for the reported loss of appetite. Additionally, a chest X-ray (CXR) performed on 2024-05-14, showed increased infiltration in both lower lungs, which could be an active infection.
While chemotherapy (TPF), targeted therapy (cetuximab: cough incidence 30%, dyspnea 49%, pharyngitis 26%), and immunotherapy (nivolumab: immune-mediated pneumonitis has occurred less frequently, mechanism non-dose-related, immunological. Onset varied; ranging from 2 to 24 months with a median onset of ~3 months) cannot be completely ruled out, it is suspected that these symptoms are more closely related to the patient’s underlying disease progression and the suspected pulmonary infection.
[exam findings]
[immunochemotherapy]
[reconciliation]
No discrepancies were identified in the medication list, and all laboratory values obtained on 2024-05-31 met criteria to initiate the planned Avastin + FOLFIRI regimen.